MENTAL DISEASES. BY T. S. CLOUSTOK, M.D. EDIN., F.R.C.P.E., PHYSICIAN SUPERINTENDENT OF THE ROYAL EDINBURGH ASYLUM FOR THE INSANE; LECTURER ON MENTAL DISEASES IN THE EDINBURGH UNIVERSITY ; FORMERLY CO-EDITOR "JOURNAL OF MENTAL SCIENCE ;" FOREIGN ASSOCIATE OF THE SOCI^TE MEDICO-PSYCHOLO- GIQUE; HONORARY MEMBER OF THE ASSOCIATION OF MEDICAL SUPER- INTENDENTS OF AMERICAN INSTITUTIONS FOR THE INSANE, AND OF THE NEW ENGLAND PSYCHOLOGICAL SOCIETY. TO WHICH IS ADDED ABSTRACT OF THE STATUTES OF THE UNITED STATES AND OF THE SEVERAL STATES AND TERRITORIES RELATING TO THE CUSTODY OF THE INSANE. BY CHARLES F. FOLSOM, M.D., FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES; ASSISTANT PROFESSOR OF MENTAL DISEASES, HARVARD MEDICAL SCHOOL; PHYSICIAN TO OUT-PATIENTS WITH DISEASES OF THE NERVOUS SYSTEM, BOSTON CITY HOSPITAL. PHILADELPHIA: HENRY C. LEA'S SON & CO 1884. WMlOO C Entered according to Act of Congress, in the year 1884, by HENRY C. LEA'S SON LilLo Edinburgh THE VERTEX OF THE BRA IN IN ADVANCED GENERAL PARALYSIS. CLINICAL LECTURES ON MENTAL DISEASES. LECTURE I. THE CLINICAL STUDY OF MENTAL DISEASES. ALL classes of men have generalized ideas of mind according to the daily experience and the practical necessities of life of each. It is not left to the philosopher, metaphysician, and psychologist to study mind. The jurist, politician, priest, and sociologist each has his own system of mental philosophy. Nay, the policeman and the house-breaker have each a crisp and concise theory, learned in the schools of experience and tradition not formulated it may be, but still definite and practical. The physician in practice has, more than most men, opportunities of seeing a wide range of mental phenomena. He comes into intimate personal relationship with men and women in circumstances where the reasoning and feelings, the instincts and propensities of human nature, are exposed to his view with as little concealment or hypocrisy as pos- sible. There are very few of the serious diseases he treats but affect the minds of his patients more or less in some way. He has to study care- fully the effects of their outward surroundings and of the impressions from without on the minds of his patients. He has to calculate the effect of his own speech and conduct, as well as those of all who surround them. He has to do with mind in its most undeveloped form up through all its stages of growth and education, and he has the opportunity of seeing the effects on it of every form of disease and debility. In addition to this he is called on to treat mental symptoms when, through their striking abnormality, they have themselves become a disease. The whole conduct of things in the world is necessarily so based on the assumption that every man is a responsible being with a sound mind.' that any exception to this, Avhen it occurs, has a very startling effect. In the early ages it was not admitted that such a thing was possible, and when a man's mind was clearly altered from its normal state, and his mental personality changed, they explained it by the theory that some other personality had entered temporarily into the man, driven out and overpowered the true occupant, and that the man was possessed with a devil, or some spirit good or bad other than his own. It is certainly no wonder that before the physiology of the brain was studied such a theory was adopted. The facts were so inexplicable on any current hypothesis of mind, that they needed a supernatural cause. Looked at from the human and social point of view, no other disease at all approaches 8 34 CLINICAL STUDY OF MENTAL DISEASES. mental disorder in the terror it inspires, the sense of helplessness it causes, the deep distress to relatives, and the disturbance of all social ties. It is no wonder that its study "was backAvard, and its treatment barbarous, up till quite recent times. But the modern scientific spirit could not, and did not, allow this field to lie fallow, and its study was hardly begun when its profound interest and great importance were seen. It was soon recognized that the mode of study of this department must be precisely the same as that required for physiology and pathology. The physiologist had to study normal mind as a form of brain energy ; the physician had to investigate abnormal mind in the same observational and inductive way as he studied diseases of the chest. It was very soon apparent that the brain was the sole organ of mind, and that the func- tions of that organ, being multiform, and having relationship to every part and energy of the body, could only be properly studied in relation to one another. It was found impossible to place quite apart the motion and sensation functions, the sleep, the animal appetites and instincts, the special senses, the speech, the memory, the love of life, the affective, the reasoning, and the controlling functions. The great problems thus opened up have exercised a fascination over many of the greatest men in our profession in modern times, men whose general professional work did not lie specially in the treatment of mental disease. I need only men- tion Pinel, Esquirol, Feuchtersleben, Pritchard, Abercrombie, Combe, Schroeder van der Kolk, Brodie, Holland, Griesinger, and Laycock. And as for the pure psychologists who have lately studied mind from the physiological point of view their name is legion. In this country alone, Herbert Spencer, Darwin, Huxley, Lewes, Maudsley, Calderwood, and Bain represent a power of original investigation and exposition seldom excelled in any one department of science ; and this is not wonderful, for if the highest functions of the brain and its derangements are not worthy of study by the best minds, what can be supposed to be so ? In a strict sense the term "medical psychology" is a misnomer; if psychology is a real science, it is one and indivisible, and you might as well talk of medical mathematics or medical physics as medical psy- chology. But inasmuch as medical men seldom have the time, and only a few of them the special aptitude, for the study of the whole field of psychology, that portion of it which has a relation to their physiological studies and the practical work of their profession has been divided off not, it is true, by very defined lines and called Medical Psychology, just as certain departments of electricity and acoustics may be called medical par excellence. An unambitious definition of medical psy- chology might be " Mind as it concerns Doctors." The necessity which exists for a knowledge of mental disease to medical men is best proved by a few facts and figures. An exceptional power has been granted by law to every member of our profession in practice of giving a certificate, the effect of which is to deprive any British sub- ject of his personal liberty on the ground of insanity. Surely such a responsibility implies an obligation on our part to know something about the subject of mental disease. How can we know that which we do not study ? And how can the medical practitioner give advice and sign such all-important certificates about a disease which, as a medical student, he CLINICAL STUDY OF MENTAL DISEASES. 35 has never seen or had explained to him clinically ? As well might you ask a man to give a life-insurance certificate that a patient was free from heart disease who had never listened to a cardiac murmur. This ignor- ance is fraught with an unusual danger. While allowing nay, practi- cally compelling us to grant lunacy certificates, the law punishes us severely Avhen they are improperly given, whether through mere ignor- ance or wrong intention ; and the common law of the land allows any man who thinks he has been aggrieved or wronged by such a certificate to sue and punish the granter of it. Several members of our profession have thus been brought into most serious trouble, professionally and financially, and themselves to pecuniary ruin. The fact that, out of 12,176 medical certificates of insanity in the admission papers sent to the office of the Commissioners in Lunacy, 2314, or one-sixth, had to be returned to the writers for amendment, does not, I fear, tend to raise the opinion of the lawyers, to whom those certificates are submitted, as to either the business power or the knowledge of insanity in our profession. I fear they are apt to ask If the knowledge necessary to sign an ordinary lunacy certificate is so deficient, what may be expected in the still more important matter of the knowledge requisite for the treatment of the disease ? I have had the 500 recent certificates sent to the Royal Edinburgh Asylum gone over, and I find that 456 of them, or 91 per cent., omit a certain point, not at all important from a medical point of view, but so essential from a legal point, that Sir Cresswell Cresswell once decided that it was a sine qua non of a valid and legal certificate according to English law. 1 And it is not as if the signing of a certifi- cate of lunacy were a matter of rarity. There were last year over 90,000 persoiu un-ler certificate as being insane in the United Kingdom. This number required over 100,000 medical certificates, or an average of at least five certificates to each practising member of our profession. This takes no account of the certificates of mental incompetency or com- petency that have to be granted for other reasons than placing a patient under care. The signing of such certificates is one duty, but not the most important, that falls to medical men in relation to mental disease. The mental hygiene of individuals, of families, and of society, the early recognition of mental symptoms, their suitable treatment, the precautions that have to be taken to prevent accidents and risk of life, the solution of the most important question of home or asylum treatment, the confi- dential family advice as to professions and careers in life, and as to the formation of engagements and marriages, the grave decisions that have to be come to as to questions of civil and testamentary capacity and criminal responsibility all or any of these questions a medical man may have before him at any time after he receives his medical qualification. When we consider that one in every 300 of the population is a regis- tered certified lunatic, the marvel is how our profession has hitherto got along so well with so little systematic teaching or clinical experience of 1 The designation and residence, marked 4 in the statutory form. The legal im- portance of this part consists in the fact that it is the only part of the certificate where the patient is fully identified. Suppose "John Brown" is heing certified without his designation and residence, what means is there of legally distinguishing him from the thousands of the same name in the country? 36 CLINICAL STUDY OF MENTAL DISEASES. mental disease. We must remember that for every person who is ob- viously insane there is probably another who has been threatened at some period of his life with its symptoms, or labors under more harmless and less obvious varieties of it. If this vast mass of brain disease is not worth study, let the general profession be freed from responsibility in regard to it ; if this cannot be done, then, in the name of all that is reasonable, let its study find a place in every medical curriculum, as urged by the Earl of Shaftesbury, the veteran head of the English Lunacy Commission for the past forty years, and by almost all the medical witnesses of repute who gave evidence before the Lunacy Law Committee of the House of Commons of 1877. But for invidious com- parisons, I think that I could show that there is more than one subject which medical students have now to study, and on which they undergo searching examinations, that cannot compare in practical importance with mental diseases. From another point of view the study is important, for there are now more than 500 medical appointments held in the three kingdoms in con- nection with the treatment of mental diseases, as Commissioners in Lunacy, Lord Chancellor's Visitors, Inspectors of Asylums, Medical Superintendents, Assistant Medical Officers, and Consulting Medical Officers to Asylums. Most of those appointments are held by those who never had the opportunity of studying in any scientific or clinical way, when students, the subjects of mental disease. Much nonsense is now-a-days talked about the relationship of the so- called specialties in medicine to the profession in general. On the one hand, they are referred to in a mysterious way, as though they were occult and very sacred side chapels off the temple of medicine, to enter which special rites had to be gone through ; and, on the other, they are spoken of as ugly excrescences on the noble form of the building. They are, in fact, simply the result of the enormous increase of knowledge, which renders one man or one set of men incapable of being equally versed in the whole field. The science of medicine has become so wide that we can only cultivate it in parts. Therefore we specialize, and must specialize more and more. But, most fortunately for the future unity of our profession, its practical exigencies are such that most of its members must know something of all its specialties. The further out the speci- alty is from the main roads, the worse it is for itself in the long-run. It is thus most difficult to avoid narrowness and the self-complacent con- ceit that always goes with narrowness. The department of medicine that has to do with the treatment of mental disease is, unfortunately for itself, a rather strongly marked specialty, for when patients are very ill they must be sent to hospitals for the insane, under the charge of medical men who make that their business, and do not usually practise much be- yond those hospitals. But then most cases have to be treated at home for a time at first by the family physician, and many cases do not need to be sent to those hospitals at all, but can be treated outside them. And as time goes on, our knowledge of mental disease will become more generally diffused and more accurate, and such hospitals will be opened as fields for clinical study, as one department of Morningside Asylum has been for many years past, this having been one of the original inten- CLINICAL STUDY OF MENTAL DISEASES. 37 tions of its founders, as stated in its rules. The state of things to be aimed at no doubt is, that all medical men should know something of all the specialties, that all specialists should be well grounded in general medicine and surgery, and that they should habitually mix with each other to widen their ideas. There is a law of demand and supply in this matter as in all others. If the general public did not put faith in specialists for certain special diseases, it would not consult them, and they would cease to exist. The study and treatment of the diseases of the mental functions of the brain has such close relations to the study of all other brain functions, and to the treatment of all other brain disorders, and the brain is so incontestable the dominant organ of the body, affecting all its tissues, controlling all functions, regulating all its energies, that there ought to be less risk of its study producing narrowness, or one-sidedness of view, than almost any other specialty. If mind is great, surely the special study of its derangements cannot be a belittling task. It might well be argued that this study is the highest branch of medicine, inasmuch as it is confessedly the most difficult, and relates to the most important part of man. The existence of mental disease affects the position and prospects of those who suffer from it more than any other disease whatever, and society and the State take more direct control of them than any other class except the criminals. When any other organ is affected by disease, it is, after all, merely a part of the man that suffers ; when the convolu- tions of the brain go wrong in their mental functions, it is the man him- f self that is affected. The rest of the human organism, looked at teleo- \logically, subserves the brain, and all the other functions of that organ subserve the mental. Everything that lives, looked at from the evolu- tional point of view, tends towards mentalization, and all the tissues of all the nervous organs of all the types of animal life find their acme in the human brain convolutions. From the purely psychological point of view, too, a study of mental disorders is essential before the laws of mind will ever be properly understood. Pathological change always throws light on physiological function. It has always been one of the great hopes of those who are interested in the prevention of mental disease, that a more thorough knowledge of its nature and treatment, and an extension of the knowledge we at present possess among the medical profession, would lead to a diminution of its total amount. If the brains that by inheritance had a tendency to this disease could be subjected during their development and education to the right sort of hygienic and preventive influences, beyond all doubt we should have less of the disease in the world. If, during matured life, those same brains could be made to avoid the exciting causes of the dis- ease, this would certainly still further lessen the evil. If educated medical knowledge were brought to bear on the customs of our civiliza- tion to secure that they are consistent with brain health, much might be hoped for ; and, lastly, if the first signs that betoken danger to the mind health w r ere observed, and the first symptoms of disease noticed, and their true significance apprehended, every physician in practice knows that their further onset and progress could often be arrested. I do not say that our knowledge of brain function in its large aspect, and the 38 CLINICAL STUDY OF MENTAL DISEASES. influences that affect it in the individual or the family, are as yet mature enough to do all these things; but how shall we know if AVC do not study? And are not many minds better than a few, and more likely to obtain fuller knowledge of the matter? There is a curious sort of morbid delicacy, too, in the public mind about the matter, which often prevents a man, when he feels his mental balance insecure, from consulting his / doctor. That abominable and cruel phase of public sentiment, which con- ( nects shame and disgrace with mental disease, does an immense amount ^ of harm to individuals and to society, and our profession should by all means fight against it. That this prejudice of the Middle Ages should exist at all, is the strongest proof of the general ignorance of the matter. Except our profession makes the study of mental disease more general, we shall never be able fully to combat and overcome this most injurious public feeling, because it is only by professional and scientific study that we get over the ideas of repulsiveness to many facts of nature. It was only when they were scientifically studied that surgery and midwifery overcame the ancient prejudices against them. The first thing the physician in his capacity of medical psychologist has to do, is to form in his own mind a standard of health. And to do this he has to go to nature. He can no more do it from books than he can form a conception of the healthy breathing or heart sounds from books. He has to do with man as he exists in nature in all the stages of his mental development. No ideal man as he ought to be will suit his purposes. If he adopted such a standard, he would be inclined to look on very many of the people he met out of sorts mentally, and fit for segregation from their fellows. He cannot, like the clergyman, go to his Scriptures or his Church and find his ideal ; he cannot look on man as A Mind or A /Soul, with a troublesome body attached ; he cannot shut the roads to his senses, and construct out of his subjective knowledge the man or the mind that is to be of service to him for comparison ; he can- not even look on him as a bundle of faculties, feelings, and potentialities tied together with the small cord of life. His method of study must be the physiological method, assisted, as far as they can be depended upon, by his own subjective experiences and those of his patients. How is the function of sensation studied? By accurate and scientific observation as to the parts of the body where it is present, by measurements of the degree in which it resides in different organs, by examination into the nerves that convey peripheral impressions to the brain, how they end in the tissues, where they go to in the cord and in the brain. In this investigation the subjective sensations of the patient are essential; but could we ever have had any real scientific knowledge of the function of sensation had we trusted to this alone? Animals cannot express their sensations in words, and yet where would our knowledge have been, had not Sir Charles Bell been able, by experiment on animals and otherwise, to demonstrate that there are distinct sets of nerves for sensation and motion? And how incomplete would have been our knowledge, how helpless our therapeutics, if the function had not been studied in its conditions of loss, diminution, exaltation, and alteration in disease! Just so it is with the function of mentalization. Whatever our philo- sophical or religious beliefs may be in regard to the Ego and the soul, CLINICAL STUDY OF MENTAL DISEASES. 39 however strongly we may feel ourselves pressed on the horns of the dilemma that to feel implies a personality, and that as yet physiology has not devised any hypothesis by which we can even conceive person- ality as a brain function in spite of this, we must, when we come to study and treat patients whose mental functions are deranged, go on the hypothesis that mentalization is a brain function as much as sensation or motion. The student of mind from this point of view is met on the very threshold by the obvious fact, that it differs enormously in its normal manifestations in different persons and sexes, in different stages of life, and in different races. He sees, too, that it is manifestly influenced by the other functions of the organism, and the organs through which those functions are performed. These facts prepare him to accept to some degree, at least, the generalizations that previous students of the subject have made as to the existence of different mental types associated with bodily characteristics, or the doctrine of temperaments and diatheses. He sees, for example, that there are certain persons in whom the nervous functions are very active, and seem specially to dominate the other func- tions. Such persons feel keenly, move quickly, and think clearly, these qualities being impressed on the form, contour, and nutrition of the whole body. He soon comes to observe that persons with such a neurotic diathesis are liable to diseases special to themselves, and that when they suffer from ordinary diseases, the neurotic predominance in their consti- tutions often affects the character and duration of such diseases. No physician of experience but knows that neuralgias, hysteria, paralysis, and convulsions are more common among persons of this type and their children than among the general population. It is a well-known fact that in certain cases of this type, acute rheumatism, for instance, will attack the brain and cord, producing coma or chorea, and that even the syphilitic poison will by .preference attack the neuroglia rather than the joints in such neurotic constitutions, and that when such people suffer from fevers they are more apt to be delirious. The facts of nature compel the physician to see that purely mental qualities and mental defects are transmissible from parent to child, and prepare him for the great part that heredity plays in psychological development and in mental disease. It has not yet been proved statisti- cally whether the shape of a man's nose or the acuteness of his moral sense is most apt to be transmitted to his children or grandchildren, but I am strongly of opinion that the latter will be found to be so. The medico-psychological student finds that, in addition to the influ- ence of temperament, diatheses, and heredity, the working of mind in each individual is influenced daily by other organs than the brain. He finds the so-called animal and organic functions and propensities so inter- woven with the purely mental functions, such interaction and reaction between them all, that he instinctively forms the conclusion and acts on it, that he must look on the whole man body, mind, and spirit from the point of view of an organism whose whole needs and capacities exhibit unity and solidarity throughout. Take, for instance, the function of alimentation. No doubt the swallowing, digestion, and absorption are chiefly mechanical and chemical processes, performed in a living labora- 40 CLINICAL STUDY OF MENTAL DISEASES. tory, and take place in the nerveless amoeba, yet he would be but a blind and narrow-sighted observer who foiled to see the enormous mental and moral influence that the desire for food, the appetite for food, and the varied pleasures, organic and conscious, that suitable food produces. He would soon in his practice meet with cases where in rational men a badly cooked dinner made life not worth having to themselves, and a torment to those about them. And a wider view would show that different kinds of foods affected the mental development of whole races of men ; that the desire to get certain coveted foods stimulated the highest ingenuity and thinking power of the wisest of men, while the want or poverty of food had made civilized men into wild beasts, as during the French Revolution, or among shipwrecked sailors. The absolute dependence of the appetite for food on brain and ganglionic integrity and sound working is so often seen by physicians, that they need no physiological proof that the appe- tite is a brain function. What stops the appetite at once when sudden fear or joy is felt ? Through what organ is it perverted during pregnancy or in hysteria ? What stimulates it to ravenousness in diabetes, if it is not a brain function ? Take a function still more nearly affecting mentalization, that of the reproduction of the species. What practical student of mind can disre- gard it ? W T hat physician can overlook the part it plays ? How directly it influences the whole affective life and history of mankind ! How the ascetic religionists of all creeds, with ideal a priori standards of life before them, have striven to set themselves free from its influence on their minds and lives ! What attempts have been made to degrade it into something almost criminal and bruitish in one age, to ignore it in the next, and to idealize it in the next! The psychological physician must simply accept the facts of physiology, and regard man as a whole, mind and body. So regarding him, he is every day beset with problems that imply consideration of the reproductive functions of the human species, and their effects direct and indirect on the minds of liis patients. And the sooner he begins to regard the whole matter from the physiological and professional point of view, just as the obstetrician does his Avork, the better for himself and his patients. It will often need all his physio- logical knowledge and his psychological study, combined with his com- mon sense and general knowledge of human nature, to expiscate the mental sympathies and aversions, the reflex and sympathetic irritations and impulses, and the paralyzed volitions of some of his adolescent, hys- terical, puerperal, celibate, and climacteric patients. A knowledge of the enormous variety of mental types seen in nature will effectually prevent the physician from setting up a Utopian and false ideal standard with which to compare deranged mind when he comes to study that subject. It is of the utmost practical importance that it should be so. Those students who attend my clinical lectures will find that there are few r questions I shall so often ask as this "What sort of man was this when he Avas reckoned well in mind?" "How does he now differ from his state then?" "Are his present mental peculiarities evolutions of his temperament?" "Are they connected with his diathesis?" "W T hat is the exact nature of the mental disturbances present?" "Is the judging, the feeling, the controlling, the resistive powers, the memory, CLINICAL STUDY OF MENTAL DISEASES. 41 or the imagination affected? and if so, in what degrees and ways?" "Is there general mental exaltation, depression, or enfeeblement present?" "Are the mental symptoms fixed or changing ? " "Is the sleep function interfered with?" "Do those disturbances bear relation to any disturb- ance of the great functions of the body ? " " What bodily functions are disordered along with the mental?" "Are there any purely bodily symptoms present?" "Was the onset of the mental disease connected with any functional evolution such as puberty, with any ordinary physio- logical process such as menstruation, or with any extraordinary physio- logical cataclasm such as childbirth?" "Are any of the other great functions of the nervous centres, such as motion or sensibility, impaired? and if so, whether primarily or secondarily to the disordered mentaliza- tion?" This is the clinical mode of studying mental disease, founded on a physiological basis. It implies something far more than merely classifying the mental symptoms of your patients, and ticketing the various groups with a name. You can easily imagine the same mental symptoms to exist, and, as a matter of fact, they very often do exist, in a girl of fifteen entering on puberty and in a puerperal woman, but in the latter case the bodily symptoms would be quite different from the former, the temperature perhaps being 103, the lochia absent, the tongue dry, the pulse feeble, the uterus septic and irritated, and the general condition so weak that a few more steps downward would lead to death ; while in the former the strength Avould be good, the pulse good, and the tempera- ture almost normal. Both cases, looked at from the point of view of mental symptoms, would be called acute mania, and yet they would be quite different in etiology, in bodily symptoms, in prognosis, and in treatment. The proper point from which to start in studying diseased mentaliza- tion being the normal physiological energy of the brain, and a recogni- tion of the fact that the normal type is not a fixed point or line, but a wide area with far diverging promontories according to age, sex, race, education, period of life, heredity, diathesis, and temperament, we next come to the question of how far mere temporary causes, such as changes in the blood supply, excesses of work, strains of all kinds, or reflex irrita- tions, affect the mental energy of the brain, but still keep within a line that may be, and ought to be, reckoned physiological. If a man w r orks till he cannot any longer lift his arm, we do not call it paralysis ; if he sleeps so soundly afterwards that no ordinary stimuli will awake him, we do not call it coma : we place neither condition out of the physiological into the pathological state. So, if a man's heart is made glad by wine or by extraordinary good news, and he shows many signs of mental exal- tation unusual in him, or if he loses blood or has bad news, and is pro- foundly depressed, we still call those states physiological, and do not count them pathological mentalization at all. A man's power of judging and comparing, his emotional condition, his inhibitory power, may all be so far paralyzed as to be in abeyance for the time, and yet we may count him perfectly free from mental disease. Nay, I have seen two men in exactly the same condition for the time being, so far as mental symptoms were concerned, and I counted the one sane and the other insane. When the limits of the physiological are passed, and a man enters on a patho- 42 CLINICAL STUDY OF MENTAL DISEASES. logical state of mind, we are often utterly unable to tell the exact line where the one ends and the other begins. As Maudsley says, you might as well attempt to draw the line between light and darkness. There is no rubicon over which a man passes from the one into the other. Insanity does not enter into a man at one door, while sanity departs at the other. That fact you should never forget, any more than the fact (to take one of the most definite ascertainable physical conditions of the human body) that you can never tell where a normal temperature ends and an abnor- mal one begins. You know that 98 is within the limits of abnormal physiological heat. You know that 108 is abnormal and pathological, but you cannot tell at what point health passes into disease. For the study of mental disorders, while the general state of mind must be the same as that in which we study ordinary bodily diseases, while it is essentially the clinical faculties that we put into exercise, yet there needs to be superadded a different kind of design and conscious effort to find out what the morbid symptoms are, more of comparison with health, more scepticism as to what the patient says directly about his own symp- toms, and far more strain in the effort to draw out the patient into a veracious and open state of mind. The constant effort to interpret the clinical meanings of subtle changes in your patient's manner, and the significance of what he says and how he says it, is wearying ; while the difficulties of delicately leading him over the ground where his mental deficiencies exist are often excessively great. His every word and act must be closely scrutinized, for they form part of the symptoms on which your diagnosis rests. An initial difficulty with the uninstructed is in the want of terms to express the mental symptoms. I have heard a man try to describe the symptoms of an ordinary case of acute delirious mania to me, and utterly fail to give any connected idea of the patient's state. Such a description as this I have often got : " He won't do any- thing you tell him. I can't make anything of him. He talks a lot of nonsense. He's just mad." Though our nomenclature for the deviations from normal mentalization is as yet unscientific and incomplete, and must one of these days be revised, yet most abnormalities are capable of being in some way de- scribed or indicated. The common symptoms met with have been classi- fied, and form the first classification of mental diseases to which I shall direct your attention. It is in reality only a classification of symptoms, not of real diseases, but the symptoms are most important and are the first things to be observed. The nomenclature this classification gives us is quite essential for our study of disordered mind, and its terms have become current in medicine, jurisprudence, and general literature. Pinel's and Esquirol's original classification of mental diseases on this principle has undergone many modifications and extensions, and I, like my predecessors, have introduced some changes. The principles on which it is founded are, to take one example, that all the states of morbid mental depression and painful feeling are classed under one head, Melancholia, just as all the painful disorders of sensibility are called Neuralgia. Indeed the melancholias bear a close analogy to the neural- gias. In the one case the mental functions of the brain are affected, in the other the common sensibility. Most cases of melancholia might be CLINICAL STUDY OF MENTAL DISEASES. 43 called mental pain. Indeed, it would be more scientifically called Psy- chalgia. Then all the states of morbid mental exaltation and excitement are classed together and called Mania, just as the motor storms and explo- sions are called convulsions, eclampsias, epilepsies, or spasms. A typical case of mania may be considered like a mental chorea or eclampsia. There is present disordered, incoherent, involuntary, purposeless raental- ization. Mania might be called Psychlampsia, if we wanted to set up a more uniform nomenclature than we have at present. There are other cases whose symptoms consist of regularly alternating mental states, usually of depression and exaltation, this rhythmical recurrence of mental pain and spasm going on during the whole course of the disease, and constituting its essential distinctive character. I think a better name for this than the one given to it by Baillarger, who first described it, viz., Folic. Circulaire, would be Alternating Insanity. Though only described as a variety of mania by him, yet I think its characters are so distinctive as to vindicate for it a special place in a complete symptomatological nosology, which I have accordingly given it. The fixed delusional states without excitement or depression come next, the Monomanias. J,ust as we now separate the monospasms and the local convulsions from the general eclampsias, I think it is better to place the cases of monomania by themselves, instead of calling them, as some authors do, partial mania. Monomania is analogous to a parges- thesia, being in fact very often due to a want of correspondence between the impression received by the brain from the special senses and the real objective impressions that have been made on them, through their getting distorted on their way from the organs of sense to the convolutions. For instance, if a man hears distinct articulate words which are merely the moanings of the wind to others, and if those subjective false voices call him bad names, he becomes suspicious of the people about him ; this becomes a morbid habit of his mind, without any special excitement or depression, and we say he labors under monomania of suspicion. This is one way in which delusion may arise. A true impression from a nerve of common sensibility may be misinterpreted, as when a man has cancer of his stomach that causes him real gnawing pain, and he says he has rats inside him that are eating his vitals. It might help you to understand this condition better if it were called Monopsychosis. When the morbid condition is one of mental enfeeblement it is called Dementia or Amentia, both very good terms. The conditions they represent are strictly analogous to the anaesthesias, pareses, and partial paralyses that result when the sensory and motor centres of the brain are respectively diseased. It might be called Psychoparesis. The next on the list, I have placed there because it fills up a gap that existed in former classifications of mental symptoms. It represents the negation of mentalization resulting from disease, where the patients are insensible to external influences, will not speak, where the faculty of attention appears to be quite gone, and where they appear not to think or feel at all. I can devise no better name than the usual one of Stupor, Amentia being already appropriated to Idiocy which, by the way, is 44 CLINICAL STUDY OF MENTAL DISEASES. never really mindlessness as the name would imply. "Psychocoma" would express this condition. Inasmuch as physiology has clearly demonstrated the existence of centres in the nervous system that control other nervous centres, giving the name of inhibition to the function of the former ; and we find that there are certain cases of mental disease, where an analogous function of the higher ideo-motor nerve-centres seems to be deranged, Avhere there are, in fact, states of want of inhibitory mental power without marked depression, exaltation, or enfeeblement, I have put those under a special class, viz., states of defective mental inhibition. Those might be called, for the sake of keeping up a scientific correspondence in the nomenclature, Psychokinesia. Lastly, there is a mental state graphically described by Dr. Maudsley, and which certainly represents facts in nature, the insane temperament or neurosis insana, or, to keep up uniformity of the classification. Psy- choneurosis. This consists more of potentialities of psychosis, of extra- ordinary and unusual assortment of mental faculties, of states of feeling that are unaccountable and uncommon, and of courses of conduct that seem merely automatic, and incapable of volitional regulation all these things being the result of a hereditary neurosis in a brain whose various functions and parts are unconformable, or whose dynamical constitution is unstable and eccentric. The following is the symptomatological classi- fication I shall use with the chief varieties of each form : 1. St ites of Mental Depression (Melancholia, Psychalgia). a. Simple Melancholia, b. Hypochondriacal Melancholia, c. Delusional Melan- cholia, d. Excited Melancholia, e. Resistive (obstinate) Melancholia. f. Convulsive Melancholia, g. Organic Melancholia, h. Suicidal and Homicidal Melancholia. 2. States of Mental Exaltation (Mania, Psychlampsia). a. Simple Mania, b. -Acute Mania, c. Delusional Mania, d. Chronic Mania. e. Ephemeral Mania (Mania Transitoria). f. Homicidal Mania. 3. States of Regularly Alternating Mental Conditions (Folie Circu- laire, Psychorythm, Folie a Double Forme, Circular Insanity, Periodic Mania, Recurrent Mania, Katatonia). 4. States of Fixed and Limited Delusion (Monomania, Monopsychosis). a. Monomania of Pride and Grandeur, b. Monomania of Unseen Agency, c. Monomania of Suspicion. 5. States of Mental Enfeeblement (Dementia and Amentia, Psycho- paresis, Congenital Imbecility, Idiocy}. a. Secondary (Ordinary) De- mentia (following Mania and Melancholia), b. Primary Enfeeblement (Imbecility, Idiocy, Cretinism, the result of deficient Brain Develop- ment, or of Brain Disease in very early life), c. Senile Dementia. d. Organic Dementia (the result of gross Organic Brain Disease). 6. States of Mental Stupor (Stupor, Psychocoma). a. Melancholic Stupor, "Melancholia attonita." b. Anergic Stupor, "Primary De- mentia,'' " Dementia attonita." c. Secondary Stupor (transitory after Acute Mania). 7. States of Defective Inhibition (Psychokinesia, Hypcrkinesia, Im- pulsive Insanity, Volitional Insanity, Uncontrollable Impulse, Insanity without Delusion). a. General Impulsiveness, b. Epileptiform Im- CLINICAL STUDY OF MENTAL DISEASES. 45 pulse. c. Animal, Sexual, and Organic Impulse. d. Homicidal Impulse, e. Suicidal Impulse. /. Destructive Impulse, g. Dipsomania. li. Kleptomania, i. Pyrornania. k. Moral Insanity. 8. The Insane Diathesis (Psychoneurosis, Neurosis Insana, Neurosis Spasmodiea}. All these varieties of mental disease find their origin in and flow out of excess, defects, and irregularities in the physiological functions of the brain. They may all arise from innate morbid tendencies in the organ, or from eccentric causes within or without the organism. The brain responds by thought, by sympathy, by instinctive and reflex influences, to almost everything in the universe outside it, and to every tissue, organ, and energy within the organism, and no two brains are alike in their reactions. If its constitution is unsound therefore, or if its conditions of energizing are unphysiological, the causes being innumerably various without and within for aberration and derangement, it results that the symptoms are almost as various as the causes of mental disease. More than of any other disease, it may be said that no one ever saw two cases precisely alike. This or any other classification, therefore, only represents types and genera, not species. Such was until recently the usual mode of studying and classifying mental diseases. It assumes that the mental symptoms are the chief things about the disease to be observed. The late Dr. Skae, following Morel and Schroeder van der Kolk, devised and directed special atten- tion to another mode of looking at mental disease, which we may call the clinical method. It endeavors to take account of causes, and of the relationship the different varieties of the disease have to the great physi- ological periods of life, and to the activities of the body other than the mental in other words, it regards the whole natural history of the dis- eases. The chief varieties of this clinical classification (which includes the pathological varieties of mental disease) are the following : 1. General Paralysis. 2. Paralytic Insanity (Organic Dementia). 3. Traumatic Insanity. 4. Epileptic Insanity. 5. Syphilitic Insanity. 6. Alcoholic (and Toxic) Insanity. 7. Rheumatic and Ohoreic Insanity. 8. Gouty (Podagrous) Insanity. 9. Phthisical Insanity. 10. Uterine Insanity. 11. Ovarian Insanity. 12. Hysterical Insanity. 13. Mas- turbational Insanity. 14. Puerperal Insanity. 15. Lactational In- sanity. 16. Insanity of Pregnancy. 17. Insanity of Puberty and Adolescence. 18. Climacteric Insanity. 19. Senile Insanity. There are a number of more rare and less important varieties of in- sanity, which I shall just allude to, viz. : 1. Anaemic Insanity. 2. Diabetic Insanity. 3. Insanity from Bright's Disease. 4. The Insanity of .Oxalur-ia and Phosphaturia. 5. The Insanity of Cyanosis from Bronchitis, Cardiac Disease, and Asthma. 6. Metastatic Insanity. 7. Post-Febrile Insanity. 8. In- sanity from Deprivation of the Senses. 9. The Insanity of Myxoedema. 10. The Insanity of Exophthalmic Goitre. 11. The Delirium of Young Children. 12. The Insanity of Lead Poisoning. 13. Post-Connubial Insanity. 14. The Pseudo-Insanity of Somnambulism: In studying mental diseases, one must constantly refer to the general 46 CLINICAL STUDY OF MENTAL DISEASES. functions of the brain, and I have thought it might be useful to point out, in the following form, the bearings of some of the most important anatomical, physiological, psychological, and pathological considerations on that study : There is in the brain an extreme com- plexity of tissues, fibres, and groupings, and an extreme delicacy of structure, these corresponding, no doubt, to the multiformity, complexity, and delicacy of its functions. There is an obvious inter- dependence of parts, and a localization of structures and functions, but yet a real solidarity of the whole brain in structure and function. There is the most direct connection, structurally and functionally, of every organ and of every tissue with the brain convolutions, and their influence is mu- tual, powerful, and constant. Developmentally and functionally one nervous ganglion or group of cells is "higher" than another, and controls or stops its action. Looking at a brain convolution, its nerve cells differ in shape and size. The} 7 are placed in distinct layers, and arranged in groups. They have been demonstrated to be different in appearance in young children, in idiots, in old persons, and in many cases of insanity, from what they are in a healthy adult (see Plate VIII., Figs. 2, 3, and 4). There is reason to suppose that many parts of the brain convolutions can ener- gize in different ways, one part being capable of doing the work ordinarily done by another ; and every part of the brain is double. The brain has a reflex and automatic action. Most of its functions are affected by this, and may be excited into activity or may be disturbed in a reflex manner by indirect stimuli, like the heart from stomach derangement. Most of the re- flex functions of the brain may be unat- tended by consciousness; or conscious- ness without volition may be present in regard to mental acts and to subsequent muscular action. The study of the physiological condi- tions of sleep, dreaming, and hypnotism, are most important, though as yet many of the phenomena are v.ery obscure. Consciousness may be complete, par- tial, or abolished in health. The brain has fixed limits of energiz- ing in all directions. All sorts of sensations, we must keep in mind, are subjective, and depend on Hence we are apt to have many func- tions and structures involved in mental diseases motor, sensory, vaso-motor, and trophic. Localization is never complete, and solidarity is never perfect. Hence peripheral lesions and disor- dered functions of organs cause mental disturbance, and vice versa. Hence disorder of the higher centres is far more important than of the lower. Hence we have a structural basis for certain forms of insanity, and for limited mental affections. If this is so, damage to, or exhaustion of, one portion of brain convolutions [as in Goltz's and Nothnagel's experiments], need not necessarily cause irretrievable loss of mental functions. In mental disease, this reflex function of the brain plays a most important part. Many symptoms can only be rightly ex- plained through it. In many mental diseases the brain acts automatically, even suicidal and homicidal impulses taking place, the volition and the consciousness being absent. The psychological facts of those condi- tions should be kept in mind in studying mental disease. No phenomena of the latter are more obscure than those of the former. In mental disease we see those condi- tions from pathological causes. Hence the danger of causing disturb- ance or paralysis of function by coming too near those limits, or overstepping them. Sensations can be misinterpreted, there- fore, in mental diseases, and, as a matter CLINICAL STUDY OF MENTAL DISEASES. 47 consciousness. The real import of most sensations, special and common, was originally only learned slowly and by in- terpretation and experience in childhood. There is a tendency in the brain to propagation, diffusion, and extension of action, normal and abnormal, and there is much trophic solidarity in the whole brain, its envelopes, and the nerves con- nected with it, quite independently of whether the tissues are cellular or fibrous, or whether the function is originating or conducting. Every mental manifestation, normal or abnormal, must be assumed to take place directly through the energizing of the brain convolutions. Mentalization differs so enormously in degree, form, and intensity in different human beings, in the two sexes, and in different races, and at different ages, that any correct standard of mental health must allow an enormous margin of psy- chological difference, apart altogether from disease. The action of "mind on mind" in healthy brains is direct, intense, and most subtle. The quality, the power of energizing and of resistance, the mode of working, the liability to disease, and the recupera- tive power of the convolutional brain tissue, are probably determined more largely in any individual by his heredity than by any other cause. Bad heredity may affect the whole brain and all its functions, or only a part of them. The chief of the human instincts, appe- tites, and organic necessities are 1. Love of life, with efforts to prolong it. 2. Desire to reproduce the species. 3. Love of offspring, with efforts to nourish and protect it. 4 Social instincts in innumerable forms. 5. Necessity to energize. 6. Appetite for food and drink. Many of these are periodic in their in- tensity or occurrence. The chief faculties, looked at from the mental point of view, are consciousness, perception, ideation and judgment, voli- tion and mental inhibition, affective fac- ulty or all that relates to feeling and emotion, memory, power of attention, re- presentation and imagination, association of ideas, and speech. of fact, many insane delusions arise in that way. This takes place abnormally in disor- dered working of the organ, disordered functional conditions extending from the encephalic tissue regulating one function to that regulating others. There is a strong tendency to progressive patholog- ical propagation of diseased processes in the brain and along the nerves. Many forms of insanity are, no doubt, explained in this way. Usually the functional propagations, like the structural degen- erations, take place in the line of physio- logical function. Hence, wherever the "origin " of men- tal disease may be, or whatever may be its "causes," mental or physical, its im- mediate cause and seat must be in the disordered energizing of the brain con- volutions. Hence the necessity for special inquiry as to the normal mental power, the nor- mal mode of working, the temperament and the diathesis in every case of mental diseases one has to study or treat. The same is the case when the brain is disordered, and hence in psychiatry men- tal therapeutics are a most important moans of treatment. Hence the importance of a study of heredity in mental disease. In some form, direct or indirect, it is rarely ab- sent in any case. In every case of insanity, attention and inquiry must be directed as to whether any of these are impaired, paralyzed, or perverted, or whether their normal peri- odicity is interfered with. It is important in examining a case of mental disease to go over these systemat- ically and test how they are affected, be- cause they are affected in different ways and degrees in different cases. 48 CLINICAL STUDY OF MENTAL DISEASES. The great physiological periods or crises of lite (dentition, puberty, adolescence, the climacteric, and senility), and the great reproductive activities (menstrua- tion, ovulation, coitus, pregnancy, nurs- ing and care of children), bring into in- tense activity, or throw out of action wholly or partially, great tracts of con- volutional brain tissue. Diseased or undeveloped function is apt to be folk wed by atrophied structure, and prolonged disturbance of function by change of structure. The mode of energizing of nervous tis- sue is normally spasmodic, and even explo- sive, in regard to certain functions. This quality is especially developed in badly constituted brains. There is reason to suppose that only comparatively limited portions of the brain can be in action at the same time, and that even the whole of the neurine tissue subserving the same limited function does not all come into activity at once. The blood supply of the brain is enor- mous (one-fifth of whole body), and of the gray matter of the convolutions five times the amount of the white. The gray matter needs, and uses up, far more blood than any other tissue in the body in proportion to its bulk. The vascular supply of the brain is derived from dif- ferent sources. The whole encephalon is divided more or less into vascular areas, each area having slight anastomosis with its surrounding areas. It is not yet proved, but it is probable, that those areas are co-related to different functions. The whole conditions of the blood supply to the brain and within the head, are pecu- liar and different from any other part of the body from its being in a shut box not subjected to the pressure of the atmos- phere, except through the vascular open- ings and foramen magnum, and from its peculiar relation to the cerebro-spinal fluid. The lymphatic spaces are also peculiar in the brain, and no doubt affect its circulation and nutrition. The vessels of the brain, large and small, are delicate, have little support but the pressure of a shifting fluid ; and the cardiac and vas- cular pressure and tension are constantly varying. It would seem as if mental emotions had a more direct and powerful influence on the vessels of the head than on those of almost any other part of the body, e. g., in blushing, etc. The various envelopes, protecting, and packing tissues of the brain, are most im- portant in themselves and in their normal relationship to the brain. They derive their blood supply from the same sources. Hence these are very apt to be attended with danger to the normal mental bal- ance when the convolutional tissue is bad in quality, unstable, or badly nourished, or specially liable to morbid explosions of energizing. In every case of mental dis- ease the possible influence of these should be inquired into. Hence prolonged mental enfeeblement is followed by brain atrophy and pro- longed mental disturbance by structural brain changes. This explains in some degree the phe- nomena of mental morbid explosions and functional defects being suddenly devel- oped when the structural cause has been a gradually advancing one, e. g., we see sudden mania, or paralysis, or convul- sion, or unconsciousness resulting from softenings or sclerosis, or inflammation, that have been going on gradually for a long time till they reached a certain point beyond which function could not be per- formed. Hence, when in certain f"rms of men- tal disease there is congestion or vaso- mot'^r dilatation of those already crowded capillaries, we have serious effei-ts on the neurine and its functions. Nothing is more common after death in insanity than to find the brain substance divided into distinct vascular and ansemic areas (Plate II.). Certain morbid appearances (e. g., " pachymeningitis haemorrhagica interna") are found within the skull, which are not found elsewhere at all. The lymphatic spaces are often found blocked up by debris. Capillary hemor- rhages (Plate VII., Fig. 2) are most com- mon in ins-anil* , and vascular disease is most common, and should always be looked for, in those who die mentally affected. Tn mental disease we often find more evident and constant disease in the bones, membranes, neuroglia, and epithelial lin- ings of the ventricles than in the brain itself. When diseased they affect the neu- rine secondarily, or are affected by its dis- eases (see Plates IV. and VII., Figs. 1, 2). CLINICAL STUDY OF MENTAL DISEASES. 49 It may be said generally that inflam- Hence we must specially examine those mation and new pathological formations packing and vascular tissues, and we tubercle, syphilis, cancer, etc. show a often find that though they are affected greater affinity for the packing tissues primarily by those new pathological for- and bloodvessels than for the brain itself, mations, yet the neurine has suffered as while the progressive degenerations tend much, structurally and functionally, as if more to affect the true nerve tissue. it had been first affected. As to the general method of clinically examining a patient, insane or supposed to be insane, the following rules may be of service: 1. Get all the information about him you can beforehand, and from the most direct sources, especially on the following points : his heredity, temperament, habits, and what sort of man he was, and what delusions he labors under, how he is changed from his former self, whether he is morbidly suspicious and will resent a medical examination, whether he is suicidal or dangerous, whether his power of self-control is affected and in what way, and his weak points mentally get, in fact, a good concise history of his case, especially noting the first symptoms and the general course. 2. In your interviews be in manner natural, frank, honest, fearless, sympathetic, and a good listener, assuming outwardly that your patient is sane. Do not be afraid to lead up to his delusions and mental weak points after you have gained his confidence and interest. Do not con- tradict or irritate until you want to test his self-control. Do not deceive him if possible. After you have satisfied yourself he is ill, try and make him believe it too. Take time ; few satisfactory first examinations can be conducted in a hurry. 3. Look on his speech, manner, and appearance as being, in them- selves, possible symptoms of his disease; be all the time in a quiet sys- tematic way, unobserved by the patient, testing his mental faculties (see p. 47) seriatim in your own mind, and be on the look-out for insane delusions or suspicions, depression of mind, exaltation, enfeeblement, lethargy and stupor, or altered feeling towards relatives and friends. 4. Note carefully the expression of face and eyes, the articulation, the manner, the muscular movements, the writing if possible, the nutrition of the body and the conformation of head. 5. Examine the state of the pulse and temperature. Never think any examination complete without taking the temperature. Many patients laboring under the delirium of fevers and inflammations would have been saved from being sent to asylums had this been done. Examine into the condition of tongue, appetite, digestion, bowels, and, in fact, go over all the great bodily functions. Especially find out about the sleep whether he sleeps at all, what kind of sleep, and for how long, and whether he dreams, and of what character the dreams are; usually the sleep is "broken" and unrestful in the early stages of insanity, the patients dream much, and the dreams are unpleasant. Examine into the motor and sensory functions of the brain and cord, especially asking about headaches and neuralgic pains. Always remember that the ordinary symptoms of bodily disease may be masked by the brain condition, so that lung and visceral diseases, injuries, etc., may exist without any con- sciousness of the patient or any obvious symptom whatever. 4 50 CLINICAL STUDY OF MENTAL DISEASES. 6. Remember there are three aspects to every case of insanity the medical, which concerns you as a physician about to treat a patient : the medico-legal, which concerns you and the patient in regard to depriving him of his liberty and of the control of his affairs, and aifects his respon- sibility to the law ; and the medico-psychological, which includes all the mental problems that arise in a study of the case. 7. Always pass before your minds the following conditions, and by exclusion determine that the case is not one of them, viz., drunkenness, drugging by opium or other narcotics, meningitis, cerebritis, brain syphilis, the fevers, sunstroke, traumatic injury to head, hysteria, the cerebral effects of gross brain diseases, simple delirium tremens, the temporary cerebral effect of moral shock, or the delirium that precedes death in many diseases and in old age. I have had cases of drunkenness, menin- gitis, typhus and typhoid fevers, hysteria, apoplexy, delirium tremcns, and the delirium preceding death, sent into asylums under my care, as laboring under ordinary insanity, and have heard of the other conditions being so mistaken. Many of these conditions and diseases may, how- ever, lead to, or be associated with, real mental disease, and require treatment as such. 8. In the clinical study of mental diseases, try and look on all the abnormalities present, mental and bodily, as being symptoms of the dis- ease, and essential parts of the brain disturbance present, and not as mere accompaniments. For instance, in a case of puerperal insanity, it is not merely the delusions and mental exaltation that are the disease, but the high weak pulse, the raised temperature, the glistening eye. tin- constant muscular motion, the dry tongue, the uterine tenderness, the absence of lochia, the sleeplessness, the paralysis of appetite, are all symptoms of the disease in a true sense that is, they are all results or essential concomitants of the brain disturbance, of which the mental symptoms are the most striking features. 9. The patient's account of himself is not always to be relied on. He may be dying, and yet to his consciousness have no symptom of it, so that he tells you he never was better in his life ; his bowels may have been moved freely that morning, and yet he tells you he has not had a motion for a week ; he may not be able to write a line, yet he says he never wrote so well in his life, etc. You must, through your reasoning, medical examination, and observation, find out what is true and what is delusion. I had once a case where a medical man certified as a delusion what an examination would have shown him to be a fact, viz., that the patient was pregnant. Certain things of the greatest import in a case of insanity the patient is very apt to deny, such as suicidal feelings, mastur- bation, etc. 10. It may be needful in some cases for the patient's safety, or that of his relations, or for the preservation of his property, to practise some amount of concealment of your profession, and of the object of your visit. The man knows so well what a doctor's visit means that he will not see a doctor if he knows him to be one, or he is so dangerous and cunning that needless risk would be run by announcing to him the object of your visit. But the public and the friends of patients have often a most CLINICAL STUDY OF MENTAL DISEASES. 51 needless desire that you should practise guile where there is no necessity in the world for it. As a general rule, there is not much to fear from the insane of the respectable classes of society. But cunning and sus- picion are the marked characteristics of many of those affected in mind. 11. Negative symptoms silence, obstinacy, stupidity, etc. are to be noted and are valuable in diagnosis and treatment, 12. Compare mentally the man as you see him with the man you may have known or had described to you. 13. The chief questions you ask yourself, and the main problems that you have to solve, are the following : Is the man mentally affected or not ? If so, is he sufficiently affected to be regarded as legally insane and irresponsible ? What form of insanity does he labor under ? Can the brain disease be localized or its pathological character determined ? What is to be the treatment ? What risks are there in the case, e. g., of suicide, danger to others, convulsions, paralytic attacks, exhaustion, refusal of food, or sudden death ? What is the general prognosis ? How long will it be before the case recovers or dies ? Is home treatment suitable or safe? or must the case be removed from home to the country, or to a hospital for the insane ? Can trained reliable attendance be got ? What mental therapeutics must be adopted, cheering or soothing, divert- ing, reassuring, checking, agreeing with him, contradicting him, or avoid- ing his favorite topics ? 14. It is always well, in a case of mental disease, to make the relations or guardians of the patient very fully acquainted with the risks of the case, to keep them hopeful if there is any hope, to give the patient the benefit of all doubts, to guard yourself in prognosis, remembering that our knowledge of mental disease is imperfect, and that the most experi- enced of us are deceived sometimes, and that there are few rules in regard to brain disorders to which there are not exceptions, to take no more re- sponsibility about sending a patient to an asylum, for instance, than fairly can be laid on a medical man, making the relatives take their proper share. It is, as a general rule, better not to be too explicit about the time it may take a patient to recover. If you undertake the treat- ment at home, or in a private house, only do so on the understanding that the nurses or attendants are under your exclusive orders. If you have to sign a certificate of insanity for placing a patient in an asylum, or taking the management of his affairs out of his hands, remember there is often a legal risk to yourself from the patient bringing an action against you, a risk that in some rare cases it is well to avoid by even getting a letter of indemnification from a relation before you sign it. 15. In regard to the question of home or asylum treatment, it depends on many other things as well as the patient's condition. His means are the first of these. Home or private house treatment of a case of mental disease is mostly expensive from the skilled attendance needed. In the midst of a city, home treatment of almost any case is most difficult. Home treatment is often impossible from the associations and surround- ings aggravating the disease. If there is a very intense suicidal tendency, the risks cannot well be obviated in a private house. If there is noise, maniacal excitement, or constant muscular motion, a private house is 52 CLINICAL STUDY OF MENTAL DISEASES. seldom a proper place for long. In a good hospital for the insane, most of the means of treatment, safety, skilled attendance, regular exercise, a proper mode of life, the administration of food and medicines, can no doubt be best attained, but then there are the counterbalancing disadvan- tages of the harm to the patient's prospects, from the cruel popular pre- judices about asylums, and the patient's own feelings about it afterwards. If you can treat a case out of an asylum, and he recovers satisfactorily, it is better for you and him. LECTURE II. STATES OF MENTAL DEPKESSION MELANCHOLIA (PSYCHALGIA}. ALL the morbid states of depressed feeling, or, as more commonly ex- pressed, of mental depression, are comprised under the term Melancholia. Like the other syinptomatological varieties of mental disease, melancholia does not admit of an absolutely precise definition. In every case there must be mental pain, hence I have suggested as an alternative the term Psyclialgia, but then mental pain does not alone constitute melancholia. As man's experience goes in the world at present, mental pain scarcely implies the idea of disease at all. The causes and occasions of mental pain from within and without are so common, as most men are now con- stituted and situated, that its presence is the rule with many, and its entire absence the exception with most. To constitute melancholia there must be disorder of brain function. A man's finger is squeezed in a vice, and he feels the most intense pain, but we do not call that neuralgia. He loses a child or a fortune, and feels intense mental pain, but we do not call it melancholia, because there is no disease. All brain reactions mentally in obedience to adequate causes are simply the exercise of physiological function, but when the reaction is quite out of proportion to the cause, or when the exercise of the activity of the brain induces mental pain of a certain intensity and kind without any outside cause, then we conclude that the mental portion of the organ is disordered, and we say that the patient suffers from melancholia. There may be in the case certain ex- citants wrongly called causes mental, moral, or physical. The man may have committed crimes, or he may have a badly acting liver, or he may be very anaemic, and all these things may cause mental pain and depression in a healthy brain, but they will not cause them in that amount and kind to constitute melancholia till his brain convolutions have taken on a disordered action until their dynamical state is that of disease, not that of health. If a man's heart is depressed in its action from a fright, we do not give this a name implying disease, unless the depression goes on long after the cause has ceased to act. This illus- trates, too, the weak points of the method of classifying mental diseases from mental symptoms alone. It is as if in cardiac diseases we should classify them as syncopes, palpitations, and anginas. Therefore, we must always keep in mind, in using such terms as melancholia, that the mental symptoms are not the disease ; we must always consciously refer those symptoms to the brain convolutions in the diagnosis and treatment of mental diseases, which are simply brain disorders of different kinds in which the mental symptoms predominate. In assigning causes, we may say that peripheral irritations, anaemias, and moral and mental shocks have caused the disease; but we must clearly keep in mind that the 54 STATES OF MENTAL DEPRESSION. mental symptoms of the disease are caused by the disordered working of the encephalic tissue. If that remains sound in structure and working, no amount of anaemia or moral shock will cause any real mental disease. States of mental depression are, in some of their forms, of all mental diseases those that are nearest mental health. They shade off by imper- ceptible degress into mere physiological conditions of mind and brain. To be able to feel ordinary pain implies an encephalic tissue for the pur- pose. To be very sensitive to pain implies that the tissue is acutely receptive of impressions. So with mental pain there can be no doubt that the healthy physiological condition of the encephalic tissue in the brain convolutions through which ordinary or mental pain is felt is one between extreme callousness to impressions and extreme sensitiveness. A man in robust health, well exercised, does not feel pain nearly so acutely, and bears it better than when he is weak and run down. Those principles apply equally to the feeling and the bearing of mental pain. To experience emotion at all to feel implies an encephalic structure for this purpose. The most casual study of the affective capacity in human beings shows us that it differs enormously in different persons. One man will lose his children or his fortune, or see the most terrible sights, and he will not feel keenly at all, because his brain convolutions that subserve feeling are not in their essential nature very receptive and sensitive. Another person will be thrown into very great grief, and feel acute agony, at the loss of a favorite dog. I had a lady patient once, A. A., who would be for days depressed, and suffer mentally, if a friend did not receive her as cordially as usual any day. She suffered mental torture if a relative spoke sharply to her, and she was absolutely para- lyzed in feeling and volition by the death of a sister. She had several attacks of mild melancholia produced by most inadequate causes, from all of which she recovered quickly and completely. There can be no doubt whatever that the finer moulds of brain are mostly very sensitive, and the poetic, emotional, and sympathetic natures have always been subject to states of painful depression of mind at the critical periods of life, and when the physical vigor was below par. Half the poets and men of literary genius give ample proof in their writings, and in the characters they have created or founded on their own experience, that they suffered at times intense mental pain. Goethe clearly looked on a period of melancholy as one phase in the development of genius. The lives and writings of Goethe, Schiller, Carlyle, Cowper, John Stuart Mill, Byron, Burns, and George Elliot show that they all had periods in their lives when they suffered intense mental pain, and at least one of them did actually pass the undefined borderland that separates physio- logical mental depression from pathological melancholia. To feel intense mental pain is mostly the necessary accompaniment of the capacity to feel intense joy. The brain qualities that give intensity to the one give also intensity to the other. We must take into consideration in every case not only the sensitive- ness and the receptivity, but also the power of bearing pain the inhibi- tory power against pain. Some brains possess great sensitiveness and also great power of inhibition. Those are the strong brains, even though their temperament and diathesis may handicap them. But when STATES OF MENTAL DEPRESSION. 55 a brain is sensitive, and has little inhibitory power, this combination is a source of weakness and of disease. There is a morbid constitution and a temperament which predisposes to mental pain, but that does not readily feel intense pleasure, and this is common enough among common men. It does not imply genius or strength in any way, and has no compensating advantages to its pos- sessors. Persons with this tendency are of the nervous variety of the melancholic temperament, or perhaps, more properly speaking, have the melancholic temperament and the nervous diathesis. They are liable to lose their sense of well-being from slight causes from within and without them. This surplus stock of animal spirits and vis ncrvosa is soon ex- hausted. They want mental balance and resistive poAver. They are verv often persons with strong unreasoning likes and dislikes, who are swayed by their instincts, and cannot correct and guide those by their reasoning power. They are often morbidly introspective and imagina- tive, and very often irritable and excitable. Bodily, they do not lay on fat at the ages when fat is physiological: their digestion is not their strong point; when tired, they are sleepless. Such a temperament and diathesis are strongly hereditary, and, I think, are very apt to be derived in the male sex from the mother, and in the female sex from the father. It strongly predisposes to attacks of melancholia as well as to attacks of mental depression in what may be called a physiological form after many bodily diseases. In such persons, fevers, lung affections, arid cardiac troubles are apt to be accompanied and to be followed during convalescence by mental depression. This is a serious complication in those circumstances, for it retards recovery, and tends towards relapses. It is, no doubt, another expression of that lack of trophic and recuperative energy of the brain which we shall see is so marked a symptom in melancholia. The great physiological crises of life teething, puberty, adolescence, the climacteric, senility, preg- nancy, childbirth, and lactation are apt to be complicated by attacks of the neuroses in such persons : loss of blood, over-w r ork, want of sleep, over-anxiety, and menstruation are also commonly accompanied by de- pression of spirits. Children of this brain constitution often exhibit a kind of child-melancholy at a very early period. I have known such a child at five years of age become intensely depressed, cry, and moan for hours, because it was afraid of the "hell" which its mother (of the same temperament) had described as being the portion of bad boys who tore their pinafores, sinned against God, and did not obey their mammas. Precocity, over-sensitiveness, unhealthy strictness in morals and religion (for a child), a too vivid imagination, want of courage, thinness, and a craving for animal food are characteristic of such children. It is most difficult to draw r a line of definition between mere "lowness of spirits," ordinary "depression of mind," popular "melancholy" or "hypochondria," and the pathological melancholia. They shade off into each other by fine degrees ; and yet it is most important to make a clear distinction. The general public, who are very fond of hearing profes- sional gossip in regard to medico-psychological problems, and of retailing as gospel the illogical travesties and popularized versions of such prob- lems which some professional men retail, have an idea that those who 56 STATES OF MENTAL DEPRESSION. have studied the subject most deeply have come to the conclusion that all men are mad; and this because we say that no man comes up to an ideal standard of mind, and few men but are subject to mental depres- sion or excitement, or to lose their self-control at times. Such a popular belief does harm, because it is utterly opposed to fact, and tends towards confusion and misconception in regard to a physician's most serious problems. It is necessary, therefore, to attempt accurate definitions, even though they may not cover the whole ground. Mere melancholy might be defined as a sense of ill-being, and a feeling of mental pain with no real perversion of the normal reasoning power, no morbid loss of self-control, no uncontrollable impulses towards suicide, the power of working not being destroyed, and the ordinary interests of life lessened, not abolished. Melancholia might be defined as mental pain, and sense of ill-being, more intense than in melancholy, with loss of self-control or insane delu- sions, or uncontrollable impulses towards suicide, with no proper capacity left to follow ordinary avocations, with some of the ordinary interests of life destroyed, and generally with marked bodily symptoms, all these things showing a diseased activity of the highest brain centres. Typical cases exhibiting these two conditions are totally different and distinguishable, and the only excuses for confounding them are that they shade off into each other, that we have no absolutely definite scientific test to distinguish them, that they are both in many cases the outcome of the same temperament and diathesis, and that they both have some- thing of the same nature, both psychologically and physiologically. A typical case of melancholia, as we shall see, runs a somewhat definite course like a fever, and has often all the characters of an acute disease, in this being to the physician entirely unlike a mere feeling of melancholy. Though, in the statistics of asylums, melancholia does not appear to be the most frequent of the varieties of mental disease, yet I think that if statistics of its real frequency in all its forms, mild and severe, could be got, it would be found that it is the most common form. In its milder varieties it is a very manageable disease at home, in this contrasting strongly with cases of mania. For this reason many cases are treated at home and not sent to asylums at all. Before seeing cases of any disease, one should know what to look for. As a general rule, one has less difficulty in the examination of a case of melancholia than of any other kind of insanity. The whole process of ascertaining the symptoms that are present is more like that in any bodily disease. The patient is usually conscious that there is something wrong with him, which is not the case in most forms of insanity. It is, in fact, the sanest kind of insanity. He can describe some of his symp- toms. Many of his subjective sensations are reliable, and are very valuable in diagnosis and treatment. It is not all a process of deduction from speech and conduct and objective signs. The patient will tell you in the first place very likely that he is unhappy, and feels mental pain and depression. He will then tell you why he feels this, or if he does not, you ask him why he is depressed, and then will probably come out the first sign of mental unsoundness. In nine cases out of ten, melan- cholic patients assign as a cause of their misery what is not its cause at STATES OF MENTAL DEPRESSION. 57 all. Here it is where their insane delusions, their false, ungrounded beliefs come in. I have analyzed the "causes" assigned by melancholies that I have had under my care during the past seven years for their own depression, and I find them to be wrong in ninety per cent, of the cases. Melancholia occurs in many forms, with very various psychological and clinical symptoms. The following are, I think, the most common varieties, and I think the study of the disease will be made easier, and its treatment become more intelligible, by considering those varieties seriatim, viz. : a. Simple melancholia. b. Hypochondriacal melancholia. c. Delusional melancholia. d. Excited (motor) melancholia. e. Resistive (obstinate) melancholia. /. Epileptiform (convulsive) melancholia. f. Organic (coarse brain disease) melancholia. . Suicidal and homicidal melancholia. Simple Melancholia. The best way to begin the study of melancholia is to take a case of what may be called simple melancholia, that is, one that is both very mild and uncomplicated, and where the affective de- pression and pain are far more marked than the intellectual or volitional aberrations. Such cases are very common and most of them are never sent to asylums or come under the notice of specialists ; indeed, many of them never come under the notice of any doctor at all, for it is charac- teristic of many of them that they have a great disinclination to consult our profession. Such a case as this is a good example : A. B., a gentle- man of 60, of a neurotic but not insane stock, had inherited from his mother a neurotic diathesis and a melancholic temperament, and was of a sensitive, vivacious, sympathetic disposition, and very studious habits. He had kept his brain at full work nearly all his life by his ambition and volitional force. The want of adjustment I count as really an imperfec- tion of brain constitution ; the inhibitory or volitional power is so great as to force the rest of the brain to work or suffer longer than its innate trophic or dynamic power would safely allow. In a perfectly ordered brain the fatigue of exhausted energizing should be so absolute as to compel rest. There should be no power in a higher centre to compel a lower centre to do more than it is fitted for. Yet we know that this is commonly counted a great power for a man to possess to be able to work, or think, or feel, or wake, or walk, not according to his innate capacity for these things, but according to his wish or the imagined necessity of the occasion. It is a dangerous power for those of a neurotic inheritance. All went on well till A. B. was about 50, when, after a big piece of intellectual work, he began to feel that he was always tired, he had a jaded feeling, his work, instead of being a pleasure, became a conscious toil, indeed, he seemed capable of feeling no joy in life any more. It did not quite amount to a sense of ill-being, but that evidence and crown of the perfect working of every organ, the undefinable but very real feeling of conscious well-being had left him. The common 58 STATES OF MENTAL DEPRESSION. pleasures of life, the society of his wife and children and friends, were no longer delightful ; indeed, intercourse with his friends by speech or letter was distinctly wearisome, and he avoided it. His courage was manifestly lessened, and he was irritable with his children, an unusual thing with him. It seemed to him as if his wife and children were less consciously dear to him, and this alarmed him and made him ashamed. He had a feeling as if he had done something wrong to cause this that it was a wrong to them in itself, and must be a judgment on him for some sin. His favorite authors and poets seemed to have lost much of their charm. His religious duties brought little comfort. His appetite was dulled; food and drinks did not tempt him, and after a meal he was uncomfort- able. His sexual desire was much lessened. Some of his instincts and propensities seemed to be altered. His bowels were costive ; his skin seemed to be harsher and drier than normal ; he had not the same feeling of reaction after cold bathing ; he could not sleep soundly all the night through, and awoke unrefreshed ; he was losing weight a little. But all this time he was not very thin or weak, and he could appear in public or to his friends just as usual. He had the power to conceal all his symptoms from those to whom he did not want them known. There were certain curious features, too, in his case. He was always worse in the morning most persons with any sort of mental pain are but if he would set himself to write a letter, or took a brisk short walk in the sunshine, or took a cup of hot coffee, he would feel better and happier. In the evenings, too, he would often, in bright light, after a good dinner with a glass or two of wine, and in the society of friends, be quite himself again, and feel almost gay for a time. He stopped work, travelled and rested, and was well in three months. Since then he has had several such attacks, some of them more severe, during which the mental pain was more positive and intense, the conscious mental prostra- tion greater, and the paralysis of volitional energy more complete, so that at times he could not possibly see his friends or put on before them any appearance of cheerfulness. At those times the beginnings of delusions showed themselves. He believed, and could not correct the false belief by reasoning, that he was lost and his prospects ruined, and that his life had been wasted and a failure, and that he had not done his duty by his profession, or his wife, or his children. At those times, too, his in- tellectual processes would be slow and torpid, his power of attention weakened, and the arrival at any conclusion impossible to him from any data whatever. When he consulted me in one of those attacks I recom- mended absolute rest, a sea voyage, almost no company, plenty of easily digested but fattening diet, some good claret, and animal food only once a day. I told him he might live on bread, butter, milk, eggs, fish, and fresh vegetables if they agreed with him and he felt that they digested well. A tonic and aid to digestion, in the shape of quinine and nitro- muriatic acid, was all the medicine I gave him. I did not think he needed stimulating nerve tonics, and warned him against opium, which some one had recommended, as against his worst enemy. I told him to live out in the fresh air as being nature's great sleep producer, appetizer, and tonic. I counselled him against any expenditure of nerve energy whatsoever, either in seeing company, travelling too fast, walking or STATES OF MENTAL DEPRESSION. 59 talking, in short, he was to take mental, affective, motor, and sexual rest. I warned his friends against the common delusion that a man in that state needed to be "cheered up" specially. My experience has been that such cheering up is a natural process that will come of itself when the brain attains its normal trophic and energizing power. I have seen many patients still further exhausted by the violent and continuous efforts made to cheer them up. I gave my opinion as to the prognosis that he would probably get over each attack as they came on him, but that he should be extraordinarily careful when he came towards old age, and said he would probably be an old man before his time. As to prophylaxis, I recommended him, when he got better, to do his work with great system and order, cutting up his day, like the face of a chess-board, into regular divisions, and filling in each with regular work, or recreation, or rest. I told him to weigh himself every month, and whenever he found he had lost three pounds to stop work and take a change or a sea voyage. I recommended the bromide of potassium for sleeplessness, in twenty-five grain doses, if fresh air would not do. That is the type of a very mild case of simple melancholia, caused by over brain-work in a person predisposed to it by heredity. In such a case it seems as if brain anaemia was present, the morning exacerbation after the physiological sleep anaemia pointing to this, relief being ob- tained by anything that determined more blood to the organ. As an example of simple melancholia with partial paralysis of volition, and of that particular kind of morbidness which consists in never "making up one's mind," along with a subtle kind of morbid introspec- tion and morbid magnification of small things, the following graphic case of A. C. is of much interest: She was a young lady who had worked far too hard at school, and so had, I have no doubt, produced chronic hypenfimia of her brain membranes, and impaired nutrition of her convolutions. I quote from her own description of her mental state. "I watch every action, word, and thought, constantly questioning them, accounting for them, excusing them, or deprecating them. Every day I rise I wish to be happy like the others. I will not torture my brain. It is a sin to steal my own happiness and that of others. I reason, resolve, and hope ; but the greater the effort to be free the greater the struggle. I have been so oppressed with this unspeakable distress that I feel as if I were two persons the one tyrannically demanding to be gratified, the other protesting and pleading. I am often in despair, and feel my life a burden. At night I am glad the day is done; in the morning I am in terror the day will be a repetition of the former. The most trivial incident will occupy my mind ; I discuss it in all its bearings, telling myself all the time it is not worthy of my consideration. Some one speaks to me, or some one is talking. If the former, I answer (often very abstractedly) with the feeling that there is something in my mind; then I return to the triviality. If I have forgotten it I must remember it, and then with a distinct effort put it away from my mind. It steals back. I tell myself that I have already discussed it, but I must repeat the whole matter to myself, and that with no ordinary process of thought. I seem to feel a strange strain on my memory, and again I have to use 60 STATES OF MENTAL DEPRESSION. an effort to banish this nothing. Again it will arise and be dismissed; and I number the times as carefully as if much depended on it. The efforts to dismiss the subject cause the blood to rush to my head, the perspiration to break, and I often find my hands clenched in the struggle. All through this I can bear a calm exterior, no one knowing how I am tortured. This fret goes on in every circumstance. I try to divert myself, and go here and there, seek the conversation of some one, seek solitude, try the piano, then a book, until I feel like a haunted creature. This strain upon my mind I cannot endure. I seem paralyzed. I can- not perform anything I wish to do. though I spend any amount of energy in fretting. "To one whose mind is healthy thoughts come and go unnoticed, with me they have to be faced, thought about in a peculiar fashion, and then disposed of as finished, and this often when I am utterly wearied and would be at peace; but the call is imperative. This goes on to the hindrance of all natural action. If I were told the staircase was on fire and I had only a minute to escape, and the thought arose 'Have they sent for fire engines? It is probable the man who has the key is at hand. Is the man a careful sort of person ? Will the key be hanging on a peg ? Am I thinking rightly? Perhaps they don't lock the depot.' My foot would be lifted to go down. I should be conscious to excitement that I was losing my chance but I should be unable to stir, until all these absurdities were entertained and disposed of. In the most critical moments of my life, when I ought to have been so engrossed as to leave no 'room for any secondary thoughts, I have been oppressed by the inability to be at peace. And in the most ordinary circumstances it is all the same. Let me instance the other morning I went to walk. The day was biting cold, but I was unable to proceed except by jerks. Once I got arrested my feet in a muddy pool. One foot was lifted to go, knowing that it was not good to be standing in water, but there I was fast, the cause of detention being the discussing with myself the reasons why I should not stand in that pool." The morbid "watching of herself," as she calls it, is a very common psychological phenomenon. The morbid doubting, too, and inability to make up her mind to action, are also common. I know a young man of a most neurotic family, whose sister, C. E., was insane and suffered from the variety of mania that I shall describe, who suffered from simple melancholia, but still more from this "insanity of doubt," for he would stop half an hour in dressing to decide which stocking to put on first, and has been known to stand for two hours where three roads met, trying to decide which to take. If hurried or forced during those morbid periods of doubt, he suffers intense mental pain, and is inclined to resist dictation. Such cases throw much light on many of the resistive and apparently "obstinate" moods of the insane, who are too much affected intellectually to describe their subjective sensations, or to give their reasons for their conduct. To return to A. C., whose letter I have quoted. She could not walk far, had palpitation when she ran, had no courage to ride, had much confusion and pain at vertex of head after reading or thinking hard. STATES OF MEXTAL DEPRE8SIOX. 61 She was fairly nourished, slept well, menstruation was regular, and she looked a sweet, bright, intelligent girl. During adolescence she had suffered much from neuralgia, severe headaches, depression of spirits, and a few attacks of hysteria, and had no surplus stock of nerve energy or trophic power. She had used up in school-work the energy that ought to have gone to build up her brain and body, and had thus caused the brain hyperoemia which I believed to be present. I prescribed life in the open air, no reading, no work amongst the poor (that had strained her by over-sympathy with them), to live largely on non-stimulating fattening food, to take bromide and iodide of potassium and strychnine meantime till she could get to Schwalbach and take the baths and chalybeate waters there. This she did, and im- proved greatly, and she writes me lately: "I have learned to have many open air interests. I have during this severe winter enjoyed myself in almost boyish enjoyments, contrary to my natural bent. I am an indus- trious gardener, and an enthusiast in poultry keeping. I am fond of drawing and painting. I now busy myself in feminine pursuits, and have a most pleasant life ; but all this is sometimes spoiled still by the former misery which renders all the occupations an effort. But I never give in ; and one looking on would never guess that -anything ailed me." I have on several occasions met with cases of this type in women of a nervous diathesis or heredity, both before and after marriage, in which the morbid doubting and introspection were very prominent features. I have met with many cases very similar to this, but each one with its own individual features. It seems to me no diseases are so individual- ized in each case as mental diseases. It seems as if the brain showed its infinite dominance over every other organ by the extraordinary variety in its derangements. One gentleman, A. D., set. 50, I used to attend, had all the features of the one I have described, with the addition of a distinct delusion, viz., that syphilis which he had had in youth had been transmitted to his children. There they were, before him, as plump and healthy, and rosy as they could be, and yet he would say they looked like death and disease, and would remorsefully point to almost invisible pimples or skin marks, and affirm they were evidence of his belief. He could not be got to go to business, though quite capable of doing it other- wise, and lost his appointment thereby. Nothing would induce him to walk out alone. In his case his bodily health was really very good. He has never quite recovered from his second attack in which I saw him. Such attacks of simple melancholia sometimes occur in young persons at puberty or adolescence. In such cases there is always a strong heredi- tary tendency towards the neuroses if not to mental disease. I was asked to see A. E., a girl of 15, some of whose mother's family had been insane, who was clever and studious, though at one time wild and mis- managed, who, after hearing a sermon one Sunday, became very de- pressed, insisted on praying with the other girls in the school, and was a little excited and demonstrative. The great feature of her case was one which, in different forms, is very common in young brains that are sub- ject to the psychoses, viz., a sort of automatic, rhythmical, and emo- tional movement. She became what she and those about her called "agonized" when left alone, that is, she would get into a state of de- 62 STATES OF MENTAL DEPRESSION. pressed brain action ; kneeling, uttering over and over again rhythmical expressions of prayer, swaying her body backwards and forwards, and wringing her hands at intervals. When with others, or at her lessons, she would appear to be quite well, but reserved and shy, and could not learn her lessons so well as before, and had no tendency to romp. She was becoming paler and thinner. She ate well. She had never men- struated. Her intelligence, when I saw her, was normal ; and she said she was quite well, and would admit no depression. She said she had headache in one temple, and felt her back weak. She admitted, on being pressed, that several things troubled her, but that they were not of much consequence, and that she was "nervous" and could not control herself at times. She said she could not take much interest in her lessons, or play, or anything else. I sent her at once to the country, to ride, walk, live in the open air, to take aloes, iron, and quinine, to read little, not to go to church for a short time, to give up coffee and tea, and animal food, but take milk and eggs ad libitum. At first, for a month or two, she used to feel depressed, slightly agitated before people, but then soon got girlish, romping, and quite well. After a tour in Switzerland she was fat, cheerful, and vigorous, with no undue religious emotionalism. She menstruated soon. If one had the guidance of such a life, much, I think, might be done by prophylaxis to ward off attacks of the neuroses. But one great contingency it is most difficult to know how to meet, viz., marriage. If such a woman marries, she runs innumerable risks in pregnancy, childbirth, and lactation ; and she may have weakly children ; if she remains single, she runs nearly as many in unused functions, hys- teria, unsatisfied cravings, objectless emotion, and want of natural in- terests in life. For herself she would get more happiness in life by mar- rying; for the world it is better that she should not. But prophylaxis in mode of living, attention to keep the body nutrition at all times up to the highest mark, and early treatment of the beginnings of the evil would, I am sure, greatly ward off the risks of another attack. I need hardly say that the " cause " assigned viz., the sermon she heard had in reality less to do with the disease than the brain she took to church, predisposed by heredity, exhausted by study, and the unnatural life at a boarding-school, starved of fresh air, and rendered unstable by the physi- ological crisis of commencing menstruation. And here I would say, once for all, about unusual religious services, exciting preaching, and "revival meetings," that, as a physician, I have no objection to them at all, rather the contrary, but I think they are only suited to stolid healthy brains, and should on no account be attended by persons with weak heads, excitable dispositions, and neurotic constitutions. The immense variety that the combination of different mental or ner- vous symptoms is capable of producing, comes out in this the simplest of all mental ailments. In some cases the mental pain is, as it were, nega- tive rather than positive, in others there is a simple blunting of the emo- tions with a tinge of depression ; in others, again, the normal gayety dis- appears, in others there is a paralysis of energy, in others a sudden ceasing to care anything about the usual interests of life, in others a natural suspiciousness of temperament becomes morbid and causes mental pain, in others a natural diffidence of disposition increases so as to be- STATES OF MENTAL DEPRESSION. 63 come a disease and to cause intense unhappiness, and in others it is a mere tedium vitce. It would swell the bulk of this lecture to utterly im- possible proportions were I to give cases illustrative of all these condi- tions, but, to show the ordinary types, I give one or two. I was once consulted about a lady, A. F., about 40 years of age; who was said to have had a similar attack some years before and to have recovered. She had given up her business, and had, therefore, no serious interests in life. She had been for some months ill. When well, she had been a clever active woman in body and mind, had conducted a business enthusiasti- cally and profitably, was sociable and a favorite with her friends. When I saw her she had little mental pain, but she had no mental or bodily pleasure. She had no energy no interest in anything. She had no delusion, except an unreasoning belief that she could not get better could be considered one. She was utterly careless about her dress, or appear- ance, or cleanliness. She was obstinate about some things ; she cared for nothing or nobody. The only thing in whic,h she took any interest was talking about her symptoms. Her memory was good, her reasoning power was good. She was thin and flabby. She would do nothing she was told. She recovered after about three years. I have seen many cases where the mental symptom of depression was so subsidiary to general nervous prostration, incapacity to walk, work, to digest food, or to fatten, and so was overlooked. I knew one case, A. G., where, as the result of many causes of nervous exhaustion, along with mild mental depression, indigestion, and the most distressing weak- ness, the cardiac innervation was so weak that the recumbent position had to be kept almost constantly for a time for fear of syncope. She recovered in two years under tonics, changes of scene, and a warm climate. Many of these cases are of the same essential nature as typical mild melancholia. American medical authors have much to say about nervous exhaustion and prostration the Neurasthenia of Beard. For the cure of some of the cases a plan of treatment has been adopted, the most irrational that was ever conceived by the medical mind. It is that of the massage, or making the muscles contract and the blood circulate faster by rapid percussion, squeezing and rubbing the body all over every day, while the patient is confined to bed, instead of walking in the fresh air. Such a plan may suit a few exceptional cases with weak hearts, but to apply it to many cases seems to me utterly absurd. It seems as if the air and climate, and the mode of life and education in some parts of America were so stimulating, that the brain there sometimes exhausted both its own trophic and energizing power, and paid the penalty by pro- longed periods of " Neurasthenia." The natural cure would seem change to a more sleepy climate. There are some instances where the higher affective life is paralyzed, Avhile the lower appetites and propensities are left intact, if not actually increased. A melancholic patient once said to me, " I canna think, canna do anything, canna care for anything wife or children, or any- thing at all, but meat, meat ! If they were all lying dead I would not care a curse if I got meat." In certain other cases there are extraordinary combinations of mental 64 STATES OF MENTAL DEPRESSION. symptoms along with the mental depression, of which this is an example, with a morbid fear of forgetting names and words : A. H., set. 64. Disposition cheerful. Temperament sanguine, but not a "nervous" man at all. Habits most industrious, steady, and ac- curate, but somewhat sedentary. A clever and intelligent business man. Mother died of some brain affection, without distinct mental disease. The only other predisposing cause was his time of life the climacteric. The exciting cause of the aggravation of the mental state which neces- sitated his coming to this asylum was the death of a sister. His present attack has been of gradual onset, beginning in a very mild way some years back, getting worse, and only assuming a form that could be reckoned technical insanity four months ago. He began by being fan- ciful and disinclined for bodily or mental exertion ; in fact, a kind of morbid laziness came over him. Laziness is more often a real disease than is commonly imagined ; it simply means, in those cases, diminished evolution of nerve energy. He gradually and steadily got worse, falling more under the influence of his morbid fancies. They produced insane conduct five months ago, which showed itself as morbid restlessness, shouting, and acting on his unfounded suspicions. He suspected that people were plotting against him, that there was a society in the next street, the members of which got into his room at night and stole his clothes and watch. He got into silly conservative habits, so that the slightest new way of the house was most disagreeable to him. He could not be got to go out and walk, or to attempt business. Once he threatened to commit suicide with a razor, but seemed to have no serious intention to hurt himself. His memory became impaired in regard to some things, and he thought it worse than it really was. His affection for his rela- tions diminished, and he lost his social instincts. On his admission into the asylum he was mildly depressed. His morbid suspicions seemed not only to be a symptom of the disease, but also a cause of depression. He was restless, fidgety, easily startled, and perversely irritable. There was some limited enfeeblement of mind in regard to certain things, e. g., inability to identify familiar persons and places, or to recall events at will, he had groundless fears, and his manner was hesitating. His memory, in regard to most matters, was unimpaired, but in regard to names it was most peculiar, for he had a feeling, almost amounting to terror, that he would forget some familiar name. His voli- tion was quite weak as regards its positive action, but there was a good deal of obstinacy. In appearance he was fairly nourished, but flabby and slightly paretic looking. His left shoulder fell a little. His left side seemed a little weaker, but about this there was a doubt, and his articulation was rather indistinct. He said he had a difficulty of swallow- ing. His tongue seemed to go slightly to the right side when put out. Sensory power was somewhat dulled, and reflexes were normal. His tongue was dry and bare in the centre. Pulse 72, and weak. Tem- perature 96.8, being generally under this in the morning, though in the evening it was sometimes 97, the average evening temperature being 96.6. This low temperature was evidently a part of his disease. He was put on strychnine and iron, nourishing diet, and as much fresh air as he could take, while every effort was made to amuse and occupy him. STATES OF MENTAL DEPRESSION. 65 He improved in pith and strength, but the apparent slight heiiii-paresis often passed to the right side. Mentally he improved, too, by being kept in a steady routine of physiological living. Anything out of this routine annoyed him exceedingly, and put him much about. After a time his mental depression centred round his fear of not " remembering names." In reality, he would remember them pretty well, but he would get most unhappy, and sometimes excited, and most irritable through the morbid fear he would forget them. In reading the newspaper, he would mark certain names down on paper lest he should forget them. He would come up to me and ask in the most earnest tone, as if his life de- pended on the answer " Doctor, can you tell me the name of that burn in Fife I fished in in 1850 ? I can't get it, and it makes me miserable." At times it seemed as if he had a dreamy mental vision of great rows of long botanical and topographical names, whose exact spelling and pro- nunciation he could not make out, and that this made him utterly miser- able. He got very stout after about six months, and went (much against his will) to the asylum seaside house, where he still further improved, and then unwillingly went home, where he lives a mentally depressed, peculiar life, fearing the loss of words and names still. If his newspaper does not come at the proper moment, or if a relative sits down on an unusual chair, he is very miserable. The things that he fears, and that put him about, are trivial unaccustomed things, and the greater things of his life do not affect him at all. A keen, sharp, business man, he cares nothing now for money or business. He shows a mild dementia, along with a mild melancholia. Every effort is made to keep up his bodily health and stoutness by good food, fresh air, and nerve tonics, and though he will never recover, he enjoys some happiness. He can origi- nate nothing, and new events annoy him. Any attempt to argue with him, or try and convince him of the absurdity of his whims, always makes him worse, for his reasoning power is greatly paralyzed. One might as reasonably try and convince a man with locomotor ataxia that he should not lift his leg so high and should put it down more steadily. His brain is clearly anaemic, and partly atrophied, and energizes feebly. The things that in an ordinary man would cause just a moment's annoy- ance, are to him very great things, from his weakness of reasoning power, paralysis of volition, and emotional hyperaasthesia. Many of his peculi- arities result from his old methodical habits remaining in an insane and grotesque form. He has been three years ill, and the slightly paralytic symptoms are proof to me that he has some brain degeneration, probably combined with a good deal of convolutional atrophy. In the cases I have referred to, the condition of simple melancholia has been the mental disease from beginning to end, but very often it is merely a stage in the clinical history, and the case soon assumes a deeper and different form of depression, or in some cases it passes into mania. It must be clearly understood that the kinds of melancholia I am describ- ing are mere varieties, and have not the characters of real diseases or pathological entities. I am taking this symptom of . depression of mind and describing it as melancholia; and I am taking this depression in certain degrees and with certain marked characters or accompaniments in different patients, and describing such cases as I would the varieties 5 66 STATES OF MENTAL DEPRESSION. of a species of plant, for convenience and clearness. A case may exhibit one form of depression of mind at one time and another at another. Simple melancholia sometimes becomes chronic, of which this was an example, having depression, but great self-control before strangers, intel- lectual vigor, morbid sensitiveness as to people knowing about her illness, want of real enjoyment of food, but eating plenty, grimacing and swear- ing in secret ; almost tearless weeping, wringing her hands, and nervous jerkings : A. J., set. 63. No children. Temperament melancholic, and diathesis nervous, but disposition lively, happy, and very energetic ; very intelli- gent. Habits active ; well educated and well bred. For four years she had been depressed, unsocial, morbidly shy, and in great dread lest her friends should know there was anything wrong. Cannot make up her mind about anything, and to any new proposal whatever is always averse ; changed in ways; not so particular as to dress and cleanliness as in health (this is very common in similar cases), and more penurious (also common). When she sees strangers or friends she can talk and behave very well, and seeins almost to enjoy it. Always objects to going any- where, but does not like to be left at home. Has no power of coming to any resolution, but much of passive resistance and objection. Conceives very strong dislikes, reads all day and very quickly, but will not sew, or knit, or play ; very acute and observant ; very sure she will never get well. As she sits and talks to one, she never looks one in the face, and fidgets and jerks, and sometimes makes faces. When alone she swears and uses most abominable language, this being of course utterly foreign to her real nature and former habits. She says she cannot help it, and deplores it a common symptom in such cases. She says she never sleeps, but this is not true, though she sleeps badly at times and walks about the room. I have another case, just like this, who "longs for sleep," and feels drowsy and sleepy often, but cannot sleep well at night, though she takes a nap for an hour every day after dinner. A. J. looks fairly well, but is worn looking, and though muscular has fallen off in weight and fatness. She had an eczematous skin irritation. Bowels costive, tongue furred. For treatment, I put this lady on very many things. Opium did harm, and so did the vegetable narcotics, all but cannabis Indica in fif- teen drop doses, which I gave with good result when she was unusually restless and sleepless, combined with thirty grains of the bromide of potas- sium. I gave her in succession arsenic, strychnine, iron, quinine, the mineral acids, the hypophosphites, salt baths, fresh air, and walking ad libitum, cod-liver oil, maltine, employment, milk, fruit, fresh vegetables, and farinaceous and fish diet, largely ringing the changes on the tonic medicines, with Friedrichshall water every other morning for the bowels. The course of arsenic did much good, being followed by an increase of body weight. Though she did not get well, yet undoubtedly she got fatter and happier and more comfortable to do with, and remains so now at the end of three years. It is a mistake to suppose that such cases do not need tonic treatment, or that it does no good. Every pound of body weight gained means a gain in nervous and mental tone. I recommended STATES OF MENTAL DEPRESSION. 67 quiet places among friends and not much travelling about, which tended to excite her. I was always in the fear of her passing into mild exalta- tion, and becoming a case of folie circulaire. I have seen strychnine, pushed too far in such a case, decidedly tend towards excitement. This lady, I need scarcely say, had sought (or her friends had sought for her) the advice of many physicians. I have seen such a case get quite well, the mental pain passing quite away after six years. This case leads naturally to the next variety of melancholia, the hypochondriacal, having many of its characters. Simple melancholia is in most cases curable ; it does not commonly require treatment in an asylum, when the means of the patient admit of suitable attendance, change, and treatment elsewhere;, it never kills directly by exhaustion, and seldom ends in dementia. The exceptions to its curability occur in the very advanced periods of life when the brain is retrogressing or degenerating, or where it occurs as an accompaniment of organic brain disease, and this is not uncommon when there is a strong neurotic heredity as Avell as such disease. Simple depression frequently precedes other forms of mental disease than melancholia, some authorities going the length of saying that it is, the necessary prelude to all kinds of insanity whatever. My experience is that it is not the necessary prelude to mania or to general paralysis, but that it is a very frequent one indeed. HYPOCHOXDRIACAL MELANCHOLIA. The next variety of melancholia is a rather well-marked one. In seriousness it exceeds the simple form. It is further away from mental health, psychologically and bodily. The symptoms are more decided and positive. Along with the aifective de- rangement there is more judging aberration, and less inhibition over morbid speech and conduct, whilst the radical instincts and habits of life are not affected, nor is the self-control so lost, as they are in the severer varieties of the disease. The mental pain has a certain superficialness and want of intensity, and the cause of it is always stated by the patient to be diseases or disorder of the bodily organs that are not real, or, if real, are exaggerated out of all proportion to their real severity in the patient's mind. As simple melancholia has a sane initial period, and many cases are never legally or technically insane at all, so hypochon- driacal melancholia has generally a sane stage and a sane twin brother called hypochondriasis, which is usually so lightly thought of, and so misunderstood, as to be for the most part thought a subject of laughter to the patient's friends, and is always popularly talked of as being a state that the patient has got into through his own fault, and could get out of by the exercise of his own volition. In hypochondriacal melancholia a sense of ill-being is substituted for the healthy pleasure of living, but the ill-being is localized in some organ or function of the body. The pa- tient's depressed feelings all centre round himself, his health, or the per- formance of his bodily or mental functions. He is all out of sorts, he cannot digest his food, his bowels will never act, his kidneys or liver are wrong, he has no stomach, his heart is weak, and he asks you to feel his pulse, which is just going to stop beating. He is paralyzed, and will not move a limb till he forgets his fancy for a moment ; he cannot think because his brain is made of lead ; he is made of glass, and will break if 68 STATES OF MENTAL DEPRESSION. roughly handled. There are no limits to the fancies of the hypochon- driac or the hypochondriacal melancholic. The way we distinguish them the sane from the insane hypochondriac is this : a man may have any conceivably absurd fancy about himself, but if he can do his work in the world, and does no harm to himself, and has a fair amount of self- control ; if he can pick himself up mentally and in conduct at will, and has the power to stop talking of his fancies when lie wishes, even though he revels in the descriptions of his own evacuations, consults all the doc- tors he can afford to pay or who will give him advice without pay, and swallows all the physic he can afford to buy, we call him merely a hypo- chondriac ; but if he has real and intense mental depression that he can- not throw off, if he loses his self-control, outrages decency openly, prac- tises things that will soon end his days, or threatens to take away his own life, and cannot at will withdraw his mind and speech from his delu- sion, then we call him a melancholic of the hypochondriacal -type, and, if necessary, put him under restraint. But, as you see, there is no line of demarcation. The one condition is often the first stage of the other. From a physiological point of view the afferent impressions from the organ implicated in the delusion sent up to the brain are unpleasant, instead of, as they should be, pleasant. The secondary cause may be real peripheral disorder. A man's liver may not be working well, and causing him uneasiness, or his stomach may not be doing its work well, or his bowels may be costive (they usually are), or he may have actual disease in the part that he says is wrong, but none of these things would cause the mental phenomena of hypochondria if the man's brain convo- lutions were working healthily, therefore the real cause must be referred to the brain. The following was a case of hypochondriacal melancholia of short duration : A. K., set. 67, unmarried. Disposition eccentric, suspicious, obstinate, and unsocial. Habits sober, but not continuously industrious. Has had three previous attacks, all of melancholia of a hypochondriacal character, treated in an asylum. No ascertained heredity towards the neuroses. It was said that he had a fall on his head when he was ten years old, and had never been right since, but I attached no importance to this story. The exciting cause of his attack was said to be masturbation, but whether this was a cause or a symptom I could not clearly make out. He was said to have become depressed three months ago, to have had suicidal feelings, to which he gave loud expression, to have lost his self- confidence ; and he became perfectly helpless and sleepless, according to his own account. He has eaten voraciously all the time, and has not fallen off in looks or weight. He came to the Asylum voluntarily, and considered his case was so urgent that he sent for me out of church. He said he felt nervous and depressed, and was afraid every minute that he would lose his self-control. He was full of fancies as to the bad state of his own bodily health that his bowels were very costive, and that he had no appetite whatever. He wanted to be most carefully examined as to the state of his lungs and heart, and more especially as to his sexual organs. He had a real chronic enlargement of one of his testicles, and insisted that he had a sore on his penis, the existence of which required STATES OF MENTAL DEPEESSION. 69 a magnifying glass to determine. His temperature, pulse, and all his organs were normal ; he was well nourished. He insisted he had a serious skin eruption, which was really a little acne on his hack. He was obtrusively suicidal in his. expressions, though it ought to have been clear to him that if he was prevented from putting an end to his life he would soon die of some one of the numerous diseases he had. He re- mained in this state for about two months and a half, and was subjected to rather a calm but strict discipline at first. He was most acute about money matters, most fault-finding as to his food, and said he did not sleep, when in reality he snored all night. He was inclined to be dis- contented because he did not receive that amount of attention which his case deserved. I never laughed at him, or pooh-poohed him, nor courted his conversation, but put him on tonics, and made him live in the fresh air, and occupy himself pretty constantly. He improved, and was pretty nearly recovered in three months from his admission, in another six months being quite lively and wanting to get married. Here is another case of a deeper and more serious nature, and of a longer duration, of the same type, the cause being disappointment, the sensations, appetites, and propensities being changed ; travel aggravating the symptoms, which were very demonstrative, with suicidal talk and ludicrous attempts ; strychnine, discipline, and fresh air having a very good effect, with a great gain in weight in six months : A. L., set. 38. Temperament melancholic. Disposition quiet, thoughtful, gloomy, energetic, enthusiastic. Habits temperate ; and very hard working. Fond of active work rather than study. Had had a previous attack, lasting three months, of the same character as that about to be described, but not so severe, and treated at home. Maternal uncle and aunt eccentric, if not insane. The existing cause of the present attack was a disappointment. It began by simple depression and in- capacity for professional work. The bodily symptoms were at first sleep- lessness, and then a curious feeling in his head as if it was made of lead. His thoughts became more and more concentrated on his health and the state of nis organs. His appetites and propensities changed. Instead of being very fond of animal food, he could not eat it at all. Instead of having the nisus generativus keenly, and indulging it freely, his sexual appetite was gone. He had had non-specific psoriasis when well, and it had disappeared (this I have noticed in insane patients very often). He had tried the usual plan of travel and change of scene, but he had been the worse for it, as often occurs in melancholia. There is scarcely a point on which I have so much difficulty in the early treatment of melan- cholia as whether to send away patients to travel or not ; and if they are to go from home, where to send them to. Quick travelling, and going to many places in a short time, is nearly always bad for a patient. Big noisy hotels and an exciting life are also nearly always bad ; but then one must have change of some sort, breaking off old associations, and different air, and scenery, and employment. The fact is, that no definite rules can be laid down on this subject ; but there are a few considerations that help to guide one. In the very early stages of the disease, when the mental pain is merely incipient, travel abroad often does good, if it is done in a systematic, methodical leisurely way. If the disease has ad- 70 STATES OF MENTAL DEPRESSION. vanced so far that the power of attention is much impaired, then a quiet country place, where there are few visitors, is best. If the bodily con- dition is very weak and exhausted, gravelling often does more harm than good. If there are delusions of suspicion very strong, so that the patient is always imagining that people are looking at him, speaking about him, following him, then the quieter he is kept the better. On admission, A. L. was much depressed, and very demonstrative in his account of his feelings and ailments. He could not read, he said, or understand what he read. He took the gloomiest view of himself and all his concerns ; was very suspicious, thinking that people were watching him; imagining he was paralyzed in sensation, and partly in motion; that he had no appetite, though he ate voraciously, and, when caught in the act, saying that his appetite was an unreal, unnatural one. He said his face and features were quite changed, and he wailfully contrasted his present looks with his former appearance. He went and made faces at the looking-glass, and said he could not help it. Said his natural aifection for his wife and children was gone, and his senses of taste and smell were dulled, but there was no evidence of it. He said his brain felt as if "made of lead," and had a "contracted" feeling. He was well nourished and muscular, and all his organs were sound but his digestive system, which was clearly out of order. His tongue Avas furred and flabby, taking the marks of the teeth ; his bowels were costive ; his pulse was 68, and good; his morning temperature was 97, and the evening 96.8. He was put on strychnine in one-thirty-second grain doses and quinine, and he affirmed that the strychnine did him good; that he felt consciously the better for it; that it pulled him up, and enabled him to exercise more inhibition over his actions, and he cer- tainly could tell when it was omitted from the mixture. He was sent to walk all about into town and into the country, and though he often re- ferred to suicide, it was assumed in his case that there was no real danger. One day he returned from a walk alone in a most excited state. He said he had attempted suicide, and disgraced himself for life. What was he to do ? It appeared he had come upon a flag-staff, and had taken one end of the rope, and tied it around his neck, and had then taken the other in his hand, and attempted to hoist himself up the staff! But there was no mark. Another day he lay down in a ditch with a little mud at the bottom, and said he had tried to drown himself, coming home with his clothes all wet. In fact, there was always an element of the ludicrous in his misery and in his mode of expressing it. Regarding the suicidal efforts and expressions of hypochondriacal melancholies, though there is little real risk, yet there is some. A doctor patient of mine once took a poisonous dose of morphia (doctors always poison themselves when they want to commit suicide, just as soldiers always shoot them- selves), and nearly died. When A. L.'s mind could be distracted, and he could be got to talk of anything but his own bad feelings, he was rational, intelligent, and his memory good, this, too, being characteristic of such patients. He got various tonics along with the strychnine viz., iron, arsenic, vegetable bitters, the phosphates but my own impres- sion is that the strychnine did the most good. In three and a half months he was so far improved that he believed STATES OF MENTAL DEPRESSION. 71 he was to get well ultimately, and this in a melancholy case is one of the first and one of the surest signs of commencing recovery. He gained a stone in weight. He could divert his attention more easily from him- self. His mental pain was less, his irritability greater, and his head felt better. He lost the most extravagant of his delusions first viz., that he would be hanged for hurting his wife. By the way, he had, what I have often noticed in such cases, exalted ideas of the beauty and high qualities of his wife and his children, and the greatness of his pre- vious position and prospects, all by way of contrast to his own misery and misdeeds. In six months he was quite well, and soon was able for hard work, which he did as well as ever, being able to make a large income. Now, the public and the friends of patients are very apt indeed to speak of such cases and treat them as if it was all the patients' fault, as if by a voluntary effort they could throw off such foolish fancies. One hears even doctors talking in the same way. They do not appear to understand how any one can believe such manifest, and what appears to them childish, nonsense about the state of the hypochondriac's health and organs, and yet be reasonable otherwise. I need hardly say how absurd such a view of the matter is. The two cases I have related show how such a condition is a real disease, beginning, running its course, and ending like many other diseases. The physiological view to take of such cases is that in them we have the brain-centres that preside over the great organic functions of alimentation and generation, etc., disturbed. When those functions are normal, and the brain is normal, the subjec- tive feeling is one of rest and satisfaction one of organic pleasure. When the functions of those organs are interfered with, or have disease in them, we have a feeling of organic pain, but our convolutions being in good order, we do not put a wrong interpretation on the pain. When the brain-centres that preside over those functions are affected by a dis- ease-storm, then, whether there is disease in the organs or not, there is often sensible disorder or lessening of function (as when the sexual ap- petite was paralyzed in A. L.), and the performance of function gives no sensible organic satisfaction. If the intellectual centres are also affected, we have the ill-being and pain misinterpreted and attributed to disease. All cases of hypochondriacal melancholia do not recover as those two did. My experience has been that this kind of case, when it occurs at the more advanced ages, is apt to be permanent, or the prelude to senile dementia. I had a medical man (A. M.) once under my care who was sixty, and who had exactly the feelings I have described, but who had no motor excitement, who would speak in the calmest manner possible about his feelings. He said that eating, though he had an appetite, gave him no pleasure; that he had no sense of repletion, so that he had to stop, not because he felt he had eaten enough, but because he saw he had eaten enough. He said that he had no comfortable satisfaction after his bowels were moved; that he had no sexual desire or power whatsoever, which was true. He never recovered, and he never could be made fat, though every physiological and therapeutic fattener was tried. He said he felt all the time as if he had a paralysis of the sym- 72 STATES OF MENTAL DEPRESSION. pathetic in his abdomen. It was he who tried to poison himself with morphia. Certainly the cases who affirm they have no stomachs nor gullets, and that their bowels have not moved for years, etc., must have the subjective feeling somewhat the same as they would have if those things were so. I have seen male senile hypochondriacs get very erotic mentally, with no sexual power. They would want female nurses about them ; would have them wash and meddle with their organs of genera- tion; would wet and dirty the bed in order to be washed by a female nurse; have enemata administered, while all this time they would affirm that they had no stomach; that they could take no food; that their bowels were never moved ; and that they were so weak that any motion was an intense pain. That hypochondriacal delusions are determined at times by peripheral organic disease is, I think, sufficiently proved by pathological evidence. Many cases of hypochondriacal melancholia are caused by want of work, want of rational interest in life, by sluggishness of mind, selfish indul- gences such as well-off old bachelors practise, by over-eating and little exercise, by too routine modes of work and living. For these the treat- ment must be work and activity and change. I knew such a man cured by losing his fortune, and having to work hard for his living, and a woman cured by marrying a poor widower with seven children. I have known a mother cured by losing a child. In fact, every variety of melancholia is often cured by a great domestic loss, a real grief taking the place of and driving out the morbid mental pain ; but before this can occur, the nutrition must be improved. There is, of course, no dividing line between the hypochondriacal variety of melancholia and any other form. Especially it runs into that variety that I have called delusional melancholia, of which, in fact, it may be regarded as a less severe variety. When the delusions in that form refer to the bodily organs or the patient's health, it is difficult in some cases to say whether the word "hypochondriacal" applies or not. DELUSIONAL MELANCHOLIA. By this term I do not mean melancholia with delusions. In that case nearly all melancholic patients would come under this class. I mean by it, that variety of the disease in which delusions, or a delusion, are from the beginning the most prominent mental symptom, in which those delusions remain throughout the disease of the same character, in very many being what are called fixed delusions in contradistinction to delusions that change in kind, or subject, or degree. As a general rule, in this variety of melancholia the delusion stands out so that the friends of the patient call it the cause of his disease, and say that if he could get rid of it he would be all right. It is the support on which all the mental pain and depression seem to hang. To those who do not consider the nature of the disease, the delusion seems the primary and causal event, the depression the secondary, and resulting just as when a prosperously happy man loses his wife and becomes sad : his loss is the cause of his grief. In some cases this may even be so, but in by far the majority of them the delusion and the depression are both results of the same cause, viz., constitutional disorder of the brain, that being developed out of hereditary tendency, and excited into action by periph- STATES OF MENTAL DEPRESSION. 73 eral disease in some other part of the body, by blood poisoning, or by unpbysiological modes or conditions of life. The delusions of melancholies are almost infinite in number and variety. I have had the chief delusions of about one hundred put down just as they were expressed to me (see p. 88). A sadder list of the causes of human misery, if they were real, it would not be easy to find. To the unfortunate men and women who hold these beliefs they are as real as if they had been true. They are enough to furnish another Dante with the causes of torture for another Inferno. It is true they were not all fixed delusions of the delusional variety of melancholia. To give a right idea of it, I shall classify the delusions somewhat, and give one or two cases representing each kind. The first kind of case I shall speak of, is that most nearly allied to the hypochondriacal last described, where the delusions refer to the patient's body or health, or to the performance of the bodily functions. These are very interesting from the physician's and the physiologist's point of view, for the one expects that by curing any bodily disease present, he will cure the delusion ; and the other finds in such a connection of mental disturbance with bodily disorder a sure proof of the relationship between certain parts of the brain and body. Not that we can in all cases demonstrate during life or after death such a direct connection. There is a very common kind of case where the delusions refer to the stomach and bowels ; I call them the visceral or abdominal melancholies. While they may be regarded as having something in common with the hypochon- driacal cases described, yet they are of a far more serious character. Their delusions are more intensely believed in, and the mental depression is much more profound. There are not only suicidal feelings and expres- sions, but serious attempts in many cases. The organic functions and appetites are far more interfered with. The appetite for food is paralyzed, and often that for drink. The sense of organic satisfaction in eating, digestion, and alimentation, generally is changed to one of uneasiness or pain. The patients thus get wasted. Sometimes real pain is felt in the abdomen. Many of them complain of an intense sinking at the epigas- trium, very like that which combined hunger and fatigue produce in healthy persons. Some complain of a constant fulness in the abdomen, others of the disagreeable feeling that costiveness produces, others of a constant sensation of emptiness and faintness. The fancies and delusions attached to, and arising out of, those real sensations are most various, as may be seen by referring to the list of melancholic delusions I shall give (see p. 88). All exaggerate their costiveness. All say their food does and will do them no good. They are so far right, that, put as much food as you like into their stomachs, it does not nourish as in health. Some say they have no stomachs, some no gullets. All say that the food will not digest. Some say they have foul breaths and $mells from their bodies that make them offensive to those about them. Some say that they have syphilis ; some that they are being poisoned, indeed, this is common ; some that the devil, or mice, or rats, or cats, are inside them. The sense of taste is certainly perverted in most of the cases, so that food tastes badly. All take food without enjoyment of it. Some take it only because 74 STATES OF MENTAL DEPRESSION. they know they will be forced to do so if they refuse ; while others resist any persuasion, and have to be fed forcibly by means of tubes passed into the gullet or stomach. Such cases are often suicidal ; they are always difficult to manage. They are all thin and sallow, and some of them die of starvation, with plenty of food in their stomachs. In some of the older cases there is a tendency to alternate constipation and obstinate diarrhoea. I had under my care in the Carlisle Asylum two most interesting cases (brothers), both of whom were visceral melancholies, and both of whom had the same delusions, viz., that their bowels were obstructed, etc. Dr. Campbell published an account of them, 1 of which this is an abstract: Two Cases of Visceral Melancholia (brothers). Delusions that their bowels were never moved ; requiring forcible feeding ; death ; bile-duct found obstructed in one, and large intestine constricted in the other. A. N. Admitted into the Carlisle Asylum on February 16, 1865. Male ; sixty years of age. No hereditary predisposition existed as far as could be ascertained, and this was the first attack of insanity. Mentally, he had, at the outset of the attack, been very dull and very hypochondriacal in his fancies. His bodily health had been tolerably good. He had been impulsively dangerous ; but had not attempted or threatened suicide. On admission he was found to be above the average height, well built, and in fair bodily health. Mentally he was very dull and desponding. His memory was good. He could speak coherently and answer questions correctly, but could not carry on a conversation owing to his always recurring to his bodily condition, which he described thus : that his belly was so much swollen that he could not take any food ; that he never got anything through him ; and that when he took castor oil it came away without moving his bowels. Nothing unusual could be discovered in the state of his abdominal viscera. April 1. Mentally remains the same as at admission ; is in better bodily health ; works on farm. No one can speak to him or ask him a question without his saying " I can't get aught through me. Will you give me some medicine ? I am about burstin'." His bowels, however, are regularly moved, and he takes his food fairly. July 1. Little change; at times refuses his food, saying that he is "bunged up." October 1. A short time ago refused his food for three days, and had to be fed once with the stomach-pump. Little change is reported to have taken place in the mental or physical state of the patient for two years and a half, when he had again on several occasions to be fed with tube, owing to his persistent starvation on the ground that his intestines were full. During 1871, on several occasions, he had to be fed. In 1872 he was most miserable in mind, frequently contemplated committing suicide, and at least on one occasion attempted to strangle himself. He wanted to hang himself with his 1 Journ. Ment. Science, Jan. 1875. STATES OF MENTAL DEPRESSION. 75 braces, and on several occasions tore his rectum and anus most severely, thinking that this passage was shut up. He went about the wards shout- ing that he had "forty days' meat in his belly," that he was "bunged up," etc. ; and, if permitted, would spend most of the day on the water- closet. A dose of medicine always produced an alvine evacuation of normal color : but, owing to the patient's dirty habits, and the practice which he said he was forced to, and which he termed "howking himself," the form of his stools could not be accurately ascertained. During this year both his ears became slightly swollen (the insane ear), then shrank, and became much misshapen. On October 16, 1874, having gradually got weaker, without any marked symptom of any special disease, he died. Almost his last words were that he had forty days' meat in his belly. AUTOPSY HEAD. There was an abnormally large amount of fluid under the membranes, and the convolutions were considerably atrophied. Section of brain showed it to be rather softer than normal. Sufficiently rich in puncta in some parts ; at base of brain it presented a slightly reticulated appearance from atrophy round minute vessels. The floors of the lateral ventricles were studded with small granulations. CHEST. In the lower lobe of the left lung, at its outer surface, there was a large vomica containing dark grumous fluid, and on the pleural coat of the lung there was, outside the cavity, some deposit of gray tubercle. ABDOMEX. Liver normal ; duct from gall-bladder and pancreas patent. The gall-bladder contained a considerable amount of thin bile. Stomach normal contained some food ; small intestine normal through its course ; large intestine contained a considerable amount of rather hard yellow feces. The large intestine, fifty inches from the caput cnecum, and two and a half inches above the sigmoid flexure, had a very constricted part three inches in extent and six-tenths of an inch in diameter. Above the stricture the gut was two inches in diameter. The portion of gut below this to the anus was normal in calibre. A. 0. Admitted June 22, 1868, set. 61. No other hereditary pre- disposition as far as known, except that he is a brother of A. N. No cause could be assigned for the attack. He is stated to have been insane for two months ; previously he had been a steady, hard-working man. The first mental symptoms noticed were great dulness, hypochondriacal fancies; latterly he had become worse very melancholic and suicidal. He complained much* of abdominal discomfort, indigestion, and costive- ness. On admission he was found to be a middle-sized man, old-looking for his age; his tongue clean. Temperature 97. Pulse 60. Skin and conjunctive slightly tinged yellow. Bronchitic rales heard over both lungs. Abdominal viscera seemed normal. Mentally was most dull and miserable, wringing his hands, complaining that he can get "nothing through him," that his "belly is much swollen," wishing him- self dead, saying that he should be hanged, etc. July 3d. Patient has been most miserable and dull since admission ; if permitted, would spend most of the day on 'the water-closet, trying to defecate, and, even after his bowels have been cleared out by the action of medicine, persists that they are full, that he needs medicine, and, 76 STATES OF MENTAL DEPRESSION. though not so noisy as his brother, goes about complaining, in almost the same words, that he is "bunged up," etc. He continued in the wretched mental state described up to October, 1869. He had been treated with vegetable tonics and blue pill, frequently repeated, as it had been noticed that his stools were clay-colored ; and as his bowels were very costive, aperient medicine had been given him at intervals. He refused his food entirely on the 17th of October, saying he was going to burst, he was so full that he could get nothing through him, etc. He was fed twice a day with the stomach-pump up to the 24th of October, when, owing to his most exhausted state, his struggling to resist the feeding, and especially his having almost died from suffoca- tion by the accumulation of mucus in his throat during paroxysms of coughing while being fed, it was deemed unsafe longer to feed him. Enemas were given him several times a day, and small quantities of liquid food were taken by the mouth. He sank, and died on November 2, 1869. AUTOPSY HEAD. The whole brain was very cedematous. Fornix almost diffluent, and corpus callosum of both sides extremely soft. The optic thalamus of the left side was in a more softened state than the right. The cerebellum was abnormally soft and cedematous. CHEST. The lower portion of the lung was much congested, and con- tained innumerable small points of tubercular deposit. The lower lobe of the left lung was congested, and full of minute points of tubercular deposit ; its upper lobe was slightly congested, and contained a few de- posits of tubercle. ABDOMEN. Liver slightly dark in color, otherwise appeared normal ; gall-bladder very small and shrunken, its Avails were very much thickened, it contained a little black bile. The gall-bladder and pancreas had sep- arate ducts entering the duodenum, that from the pancreas entering lowest. The duct from the gall-bladder was not patent at its termina- tion ; it ended in a cul-de-sac of the intestinal wall. The wall of the intestine was thickened at this part, and looked like an ulcer inside of the intestine. These cases show that different kinds of abdominal distress and dis- turbed alimentation may excite the same delusion. Extreme constipation existed in both cases, but from quite different causes mechanical ob- struction in the one, and lack of bile in the other. We know, of course, that neither constipated bowels, nor lack of bile, nor mechanical obstruc- tion, is necessarily followed by such mental delusions. For these we need something else, viz., brain convolutions predisposed to disordered action which results in a mental misinterpretation of real pain or organic dis- comfort ; and in those two brothers, though their family history was un- known, that cause of the insanity was no doubt present in the shape of a hereditary neurosis. One is justified in thinking that both causes were needed to produce the result in those men, who might have died reputedly sane but for the abdominal diseases which converted the heredity from a potentiality into an actual disorder. It will be observed that the brain in both cases presented signs of organic degeneration. There is no doubt a special tendency for abdominal and cardiac injuries and diseases to be accompanied by mental depression or a sense of vague STATES OF MEXTAL DEPRESSION. 77 discomfort, which is the opposite of the feeling of general well-being and organic satisfaction. The two following are cases where an organic lesion was found after death, that had evidently determined the character of the delusion : The first was a case of visceral melancholia, beginning as simple melancholia, then expressing religious delusions, then visceral delusions ; "no oesophagus;" refusal of food; forcible feeding; death; intestine large, and scybala found almost obstructing bowel. A. P., get. 58. Disposition lively, social, cheerful. Habits active and industrious. Two previous attacks of melancholia ; one lasted about two years ; treated at home, and by change of residence. Paternal aunt died insane. Exciting cause not known. First symptoms : change of dispo- sition and habits, depression, inactivity, apathy, sleeplessness (treated with morphia). Recent symptoms : deep depression, despair, religious delusions, e. g., that there was no hope for her, that she had committed an unpardonable sin ; restless ; sleepless ; no attempt at suicide. Dura- tion of attack : two months. On admission, great depression, taciturnity, and delusions as to her spiritual state. She was quite coherent and free from excitement. Memory good. Physical condition poor. Nervous system and thoracic and abdominal organs apparently healthy. Appetite good. She slept little for nine nights, getting no morphia, and missing it very much. Took sufficient food. Was quiet, reserved, and depressed ; thought her case a hopeless one. Considerable improvement occurred at first, and then greater depression and a change in the character of the case, the delusions now assuming the visceral character. Became restless, excited, and intractable. Said she could not live, and tried to strangle herself. Refused her food because she said she had no gullet. Grew steadily worse. Abdomen full, and a tumor was diagnosed. Persistently refused food. Had to be fed with nose-tube thrice daily, and very frequently vomited the meal. Bowels had been obstinately constipated ; laxatives and enemata being employed, caused unformed evacuations. Breath became extremely offensive, mouth covered with sordes. Died six months from beginning of attack, and four months and one week after admission to the Asylum. AUTOPSY. Beyond very slight atrophy of the gray matter, there was no apparent brain disease. The thoracic and abdominal organs were healthy, with the exception of the intestines. The intestinal walls were greatly distended at different parts, the large intestine being particularly so affected. In the large intestine huge masses of hard fecal matter were found, which must have been there for a considerable time, judging from their appearance and the amount of irritation set up in the intestinal walls. On several parts of the internal surface of the latter there were pretty considerable extravasations of blood and traces of inflammatory action. One huge mass of fecal matter seemed to block up the external orifice of the intestinal canal. Fortunately all such cases do not terminate in death, nor are they all accompanied by organic disease or obstruction of the viscera. Most of them are incurable, and yet after death we find no organic disease to account for the symptoms during life. Indeed, this is the case with the 78 STATES OF MENTAL DEPRESSION. greater number of the typical cases. As the result of a statistical inquiry into this form of insanity, taking all the cases I had notes of, I arrived at the following results. In the first place, out of the visceral cases only one-fifth completely recovered, a few making a partial recovery, the acute misery and the delusions passing off, but some depression and some enfeeblement of mind remaining. Of those who recovered several relapsed into the same mental state at older periods of life, and then remained incurable. Another fact in regard to this disease came out in the statistics, viz., that every typical case was over fifty years of age. Some of the cases in which there was no organic disease found after death, had been characterized by a tendency to a sort of passive diarrhoea during the later stages of the disease, the best cure for which I always found to be the recumbent position. It seemed to be a diarrhoea from deficient motor innervation of the bowels a sort of alimentary atony. This was usually accompanied by tissue wasting throughout the body, a low tem- perature, an incapacity to resist cold, a blue chilly state of the extremities, and a tendency to congestions, tubercles, and low inflammations. In fact, such conditions seem the natural termination of life in such cases ; or intercurrent diseases engendered by those conditions, such as bronchitis, catarrhal pneumonia, tuberculosis, gangrene of lungs, etc. The following is another very good example of this important and troublesome class of cases, there being present delusional melancholia, caused by exhaustion from over-work, the delusions being that all animal food given was human flesh, and was poison ; with refusal of food. Two attacks first recovered from with perfect mental capacity for hard work; second attack ending in death. A. Q., set. 50. At first attack, which consisted of mental depression and delusions that his food was "raw human flesh," so that he would not take it, he lost over two stones in two months the disease had lasted before he was placed under treatment in the Asylum. The cause had been mental anxiety and over-work, and no heredity was admitted. The strange fancies of some melancholies were well illustrated by his imagining that the arrow on the paper in the crown of his hat had been put there to indicate that he would be put in a dark coal-cellar if he did not eat arrowroot ! He also believed his food was poisoned ; and he would not use the water-closet, as he imagined it would interfere with the drainage. He had cold hands and feet ; his skin was blue and cold ; he lost his big toe-nail from a chilblain ; and he had a boil on his face. He pointed to all these things in proof of his dekision that he had been poisoned. He had oxaluria, and his bowels were costive. He was fed well, got stimulants and fresh air, and gained in weight ; but in seven months from the beginning of his illness he would still take no interest in anything but the state of his bowels. In about a year from the beginning of his illness he had recovered from his depression, and had got rid of his delusions, and he was strong and stout. In eighteen months he was doing an enormous professional business, implying the greatest mental strain, and the exercise of the highest intellectual ability. He did so for eight years, and then the symptoms, mental and bodily, that I have described came on again, and he had to be placed under treatment in the Asylum. This time he was over sixty. He was more STATES OF MENTAL DEPRESSION. 79 emaciated ; he showed marked signs of arterial degeneration ; his prostate was enlarged, and his urine troubled him both by retention and inconti- nence at different times ; he Avas scarcely able to speak above a whisper ; and in his gait, attitude, and movements he gave the impression of an old man. In spite of every treatment tonic, nerve-stimulant, fattening, and stimulant he grew worse. He was compelled to take enough food, but it did not fatten him. He was constantly troubled with a mild diarrhoea, and he could not always keep himself clean. Whenever in any form of insanity the patient persistently passes urine, and especially feces, in his clothes or bed, it is a bad sign on the whole. It appears to imply always a profoundly diseased interference with the radical instincts of man. The only exception to this bad prognosis from this cause is when it happens in acute delirious mania and in stupor. The patient was removed home, and gradually sank in about nine months from the beginning of his second attack. Such a case shows that the morbid brain action, the trophic paralysis, the actual visceral derangement and its exaggerated mental representation, can all be recovered from. It also shows that there is liability to return with the decadence of function and degeneration of tissue of advancing life. As we shall see when I come to speak of the climacteric period and its characteristic mental disease, the great physiological crisis has much to do with such a case. Medicine, rest, food, fresh air, nursing, physio- logical conditions of life, can do much, but they cannot arrest the tendency to death inherent in tissue, and organ, and organism, when their appointed time of living has run. If we could connect the visceral delusions and depressions in every case with visceral lesions, as in the cases of A. N., A. 0., and A. P., we should place them in the clinical classification as visceral insanity. As we cannot yet say there is any visceral lesion or disorder at all in many of them, but merely a delusion that there is, I have simply described the clinical facts in regard to them, and avoided a new "form of insanity." The following was a complicated case of delusional melancholia, with one central and many peripheral causes of irritation and exhaustion, viz., a cancerous tumor of the middle lobe of brain, disease of kidneys, liver T pylorus, etc. A. Q. A., set. 58, a lady of good education, cheerful and frank dispo- sition, domestic and industrious habits, who had enjoyed good health, and had a family of several children. Temperament not neurotic. No hereditary predisposition to insanity. Predisposing cause of attack seemed to be domestic anxiety, and a sudden alarm of fire. Had been falling off in flesh, appetite, and strength before mental attack, but became depressed some weeks before admission, and soon became possessed with the delusion that she was very wicked, that she had syphilis, and would infect those round her. She refused food, was sleepless, and imagined she had no passage in her bowels. On admission there was extreme depression ; says she is very wicked, is lost, has syphilis, and is not fit to be here. Has an anxious, worn, pinched expression of face. Cannot be interested in anything outside herself. Memory seems fairly good. Is coherent, and can answer questions; very thin; color very bad. Has enlargement of the thyroid 80 STATES OF MENTAL DEPKESSIOX. body, with prominent eyeballs. No paralysis or anaesthesia. Tongue slightly coated. Bowels very costive. Pulse 88, weak. Temperature 98.3. Patient was ordered a tonic quinine and hydrochloric acid and to have two glasses of sherry daily, with good nursing, and plenty of easily digested food and fresh air. For a time patient showed a slight improvement, but this proved very temporary, and the melancholic condition became aggravated. She slept badly, occasionally having a good night, but generally being restless, with broken, disturbed sleep. The appetite was much impaired, patient taking very little food, and ultimately refusing food altogether, so that on one occasion she had to be fed with the stomach-pump. The tongue was clean, but dry ; the bowels were costive, and had to be regulated by occasional doses of compound licorice powder and other aperients. Patient had a pinched, anxious expression of face, and lost flesh. Mentally she was in a condition of great depression, with numerous delusions of a melancholic character. She fancied that she was lost to all eternity, that she had misconducted herself in youth, and that she was now suffer- ing from a disease which she had contracted at that time ; that she had ruined her husband and family, and that there was no place for her at home at all. Along with this there was considerable enfeeblement of mind ; she was childish, querulous, and unreasoning in her conduct ; and her power of attention and her memory were much impaired, especially as to recent events. After having been in the asylum for weeks, she would maintain that it was only one long day since she came ; she com- plained that the days never came to an end, and that she was compelled to take an extraordinary .number of meals in each day. This perversion of the sense of time and number is not uncommon in melancholia. When asked to go to dinner, she would querulously reply that it was not half an hour since she had taken breakfast. She showed little interest in what passed around her ; could be got to take little or no part in work or amusements, but was always harping upon her own miserable condi- tion, and in conversation giving ready expression to her delusions. She was very disinclined to take the usual open-air exercise, and would meet the doctor on his morning visit with the constant request that she should be allowed to remain in the parlor, as she was too weak to walk. When compelled to go out, she thought that she was being treated unkindly, and this idea at times almost amounted to a delusion that she was per- secuted by the attendants ; and when visited by her friends she would frequently make ungrounded complaints against them. With occasional slight variations from time to time, patient's mental condition during the winter continued much the same as that noted above depression and enfeeblement, with delusions of a melancholic type. But during all this time her physical health was steadily deteriorating ; she took her food badly, and only with much coaxing (though the stomach-pump did not again require to be used) ; she was restless at nights ; the bowels were still costive more or less. There were great emaciation, a slightly jaundiced tint of the conjunctiva, and a markedly cachectic appearance, such as to make one at once suspect that the patient might be laboring under organic, and possibly malignant, disease. From time to time repeated physical examination of the thorax and abdomen STATES OF MENTAL DEPRESSION. 81 was made, with the object of detecting any organic disease that might exist, but no evidence of such disease could be found. Beyond frequently containing a very large quantity of urates, the urine, indeed, usually showed nothing abnormal. It was difficult to make a satisfactory ex- amination of the organs, as the patient complained bitterly whenever she was touched, and her statements as to the parts in which she felt pain or tenderness on pressure could not be relied on. Great oedematous swelling appeared in the feet, and gradually extended up the legs. The pulse became small and very thready, and latterly could sometimes scarcely be felt at the wrist. The bowels at this time were much more regular than previously, and the stools more natural in appearance. Patient grew weaker and Aveaker, and ultimately sank, a year after admission. AUTOPSY. Body much emaciated ; extensive bed-sore over sacrum. BRAIN. Vessels at base atheromatous. Vertex healthy looking. There was a tumor, the size of a hen's egg, growing from the upper part of petrous portion of the left temporal bone, weighing half an ounce, and attached to the inner table of the bone, which was somewhat softened. The tumor was encysted in the brain matter, but not attached to it, lying quite free in a cup-shaped cavity. The contiguous brain substance was flattened out and somewhat softened. The cancerous mass, on microscopic examination, was found to consist of small cells lying in the meshes of a delicate stroma, although much resembling brain matter, but distinguishable from it by the absence of the characteristic larger brain cells of the gray matter. The brain was softened near the tumor, and very amemic. ABDOMEN. There were several small secondary masses of cancer at the pyloric end of stomach, the orifice of which was constricted. No secondary cancer in liver, kidneys, glands, or other organs. The splenic artery was enormously tortuous and dilated. Liver was fatty, with thickening of the coats of its arteries arid bile-ducts, and considerable increase of fibrous tissue round them. The fibrous tissue round the bile- ducts was deeply stained with bile even to the smallest duct. KIDNEYS. Right kidney full of very large cysts; substance otherwise normal. Left kidney had marked cystic degeneration. The renal sub- stance was almost gone, its place being taken by numbers of cysts, many of them containing dark fetid fluid matter. In regard to the duration of each of the distinct diseases, the only guides one has in forming an opinion are the pathological appearances after death. Not one of them produced unequivocal symptoms during life by which they could have been certainly diagnosed, or their course determined. The cystic condition of kidney seemed undoubtedly to have been the first departure from health. But then, on admission, it did not cause albuminuria, oedema, or any other symptoms referable to renal diseases. It was only, in fact, within two months of death that this was so. The contraction at the pyloric orifice of the stomach must have existed some time, but there are no data for saying how long. There is fair reason, however, for connecting this with the loss in flesh, falling oft in appetite, and discomfort in the region of the stomach and bowels, which came on a few months before the insanity. The liver had clearly 6 82 STATES OF MENTAL DEPRESSION. been disordered in its functions ; and obstruction of its ducts had been suspected by us during her disease, and the urine examined for bile, just a trace being once found in it. In fact, I had a strong suspicion of ob- struction of its ducts, from the mental symptoms being similar to those of A. N. and A. O. (pp. 74 and 75). The cancerous tumor of the brain had been utterly unsuspected, and had produced no symptoms discoverable whatever, either sensory or motor. Such a tumor as that, I cannot imagine would have grown to such a size within the skull, where there is so little room for ready ex- pansion, in less than twelve months, and probably it took a longer time than that. My experience of such tumors would lead me to say that its duration was over a year. The cause of death in this case was really the exhaustion and failure of bodily nutrition, caused by the presence of all the diseases and morbid states of mind and body. Their combined evil eifects had reached that point which was incompatible with life. The mental symptoms were from the beginning, in many respects, of that type of melancholia which has been associated with disorders or diseases of the alimentary canal. The cry of the organism for suitable nutriment, which is revealed to consciousness as appetite, was quite abolished, and there was instead, at one time, a strong repugnance to food. Digestion was impaired. There were clearly strong feelings of organic discomfort after eating. The bowels were very costive, and her delusions exaggerated their costiveness into months between each move- ment. Her abdomen and abdominal muscles felt hard and stretched. The hypersesthesia she had w r as referred for the most part to her bowels. With all this there was extreme emaciation, though plenty of nourishment i i i was taken mto the stomach. I think one may confidently refer the direct cause of the special delu- sions in all those cases to a disordered working of that portion of the brain which presides over the function of alimentation ; and, secondarily, to a disordered working of the organic nerve ganglia that so abound in the abdomen the sympathetic system of nerves, the semilunar and visceral ganglia, and the small nerve ganglia in the coats of the bowels. Ferrier thinks that the posterior lobes of the brain are the seat of the organic brain functions, but there is no proof of this, and the lower portions of the middle lobes are yet quite unappropriated as to special functions. It may be that their functions are those of presiding over and regulating alimentation and digestion. The real cause of the aboli- tion of the normal food appetites in so many diseases and states of dis- ordered health, and their perversion in other instances, is unknown, but, beyond a doubt, we must refer many of them to some central cause in the brain. The whole of A. Q. A.'s case was interesting from there being disease in the brain which probably caused the melancholia, and disease in the abdominal viscera which determined its special character and its delusions. In two very marked visceral cases of melancholia, with delusions of no stomach and intense repugnance to food, I have had the semilunar, and many of the sympathetic ganglia of the abdominal plexus taken out, PLATE VTI. James Robertson DeU G y/aterstonlSaas.Litho Edinburgh STATES OF MENTAL DEPRESSION. 83 hardened, and cut into sections, and examined them microscopically, and in both cases I found the nerve-cells markedly degenerated, atrophied, and pigmented (see Plate VII., Fig. 1). Some of the cells had almost disap- peared, and very few of them in any of these sections were normal. Whatever are the precise functions of those ganglia, beyond a doubt they could not have been properly performed by those diseased cells. The delusions refer to electricity or some such imaginary source of annoyance in a large number of instances, as in this case, which recovered : A. R., set. 44 ; education average. Disposition reserved, unsocial, suspicious, grasping ; habits steady arid industrious. One previous attack of depression with delusions lasting a month ; treated and cured by travel and rest; no insanity in family. Exciting cause: over-work and business anxiety. Attack has lasted one month, though he had been dull before. Became restless and sleepless ; lost appetite ; very depressed ; threatened violence to himself; was very suspicious, and abso- lutely possessed with the delusion that an electric battery was at work in his house acting on him, and causing pain and sleeplessness, On admis- sion, great depression shown in expression, language, and behavior. Talks all the time about people working on him with an electric battery in his bed, and that enemies are conspiring to ruin him. General health weak; condition poor; tongue foul; bowels costive; conjunctivas yellow; muscles flabby. For a week after admission he remained extremely depressed, reserved, full of the battery delusions, and suspicious, and slept very little. Under light digestible food and milk, tonics, podophyllin every night, fresh air, and constant companionship, he improved steadily, became more cheerful and sociable, talked less of the delusions, slept better, and had a good appetite. Within three months he was able to live in one of the detached houses; and in two months more he was dis- charged recovered, having gained a stone and a half in weight, looking fresh, and mentally quite happy. During recovery he passed through the common enough stage of belief in the existence of the battery at one time, though he said it was not worked on him then. After complete recovery he laughed at the whole idea as being a morbid fancy ; but he said his sensations had been most uncomfortable, that he used to feel sudden pains, to twitch and jerk and jump up in bed, and had imagined those motor and sensory nervous symptoms meant that he was worked on by a battery. The pathological explanation of them is no doubt this, that through brain disorder or peripheral disease, neuralgic and perverted sensations are felt, and their meaning misinterpreted by the disordered intellectual centres, which are at the time not in a condition to be affected by evidence, or capable of reasoning rightly. I once had an epileptic patient who, at times after the regular fits, used to twitch in her limbs, and who would point to the twitchings (that were evidently accompanied by pain) and say "Look how it works on me," meaning that some one was electrifying her. Such delusions of annoyance or being worked on by electricity, magnetism, or unseen agency, if they last long, while the depression abates, are very unfavorable as regards prognosis. But, so long as there is distinct depression, of which these delusions are an accompaniment, the case should be held to be curable, and treated as such. 84 STATES OF MENTAL DEPRESSION. There is a popular notion that religious cases of melancholia are very unfavorable. It is meant that cases with intense despondency as to their religious condition, and delusions as to their eternal damnation, as to having committed an unpardonable sin. having offended the Holy Ghost, Laving led most wicked lives that "will never be forgiven, having failed to instruct their children properly in religious truths, having caused much sin in others by their example, having neglected the services of religion, having been hypocrites and impure in heart and motive while professing Christianity, and kept up religious appearances so as to deceive the world, being possessed by the devil, etc.. that such cases never get well. No doubt there are some bad cases of religious delusional melancholia, and such patients are apt to make a strong impression on those who see them. In reference to them, the religious superstitions of the Middle Ages as to diabolic possession still cling in the popular mind. They are always taken to the clergy first for comfort and spiritual help. It is difficult to draw the line, too, between them and the religious "conviction of sin" and doubt and depression which, according to many systems of theological belief, are a normal part of the individual religious life. John Bunyan's prolonged depression and "darkness." which is accepted by many as a normal religious experience, having no connection what- ever with mental disease, is sufficiently like some of the cases to cause a feeling of confusion about them. Some of the cases have been called by special names Demonomdnia, etc. There is no doubt, too, that the religious instinct of man is one of the deepest and most central parts of his psychological constitution, and is often cultivated and devel- oped from childhood in a way that few of his other faculties are ; so that, when perverted, it causes intense general emotional disturbance. These reasons are sufficient to account for the general idea that the prognosis in religious insanity is bad. But, as a matter of fact, this is untrue. A very large number of cases of melancholia have a religious element in them, and it certainly does not prevent them from getting better. The following is an example : A. S., set. 29. Disposition cheerful. Habits industrious. Comes of an excitable, eccentric family. Cause of her illness ill-treatment by her mistress and amenorrhoea. First symptoms, mental confusion and depression, and falling off in bodily looks, appetite, strength, and her head feeling "queer." On admission she had mental depression, as indi- cated by her expression, attitude, and the general tone of her conversa- tion. There was also slight mental enfeeblement ; her memory seemed to be greatly impaired. She labored under various delusions of a religious kind, e. We had a young man, C. Z. B., in the asylum, who, when he first became insane, attacked a man on the street, and got his own eye knocked out, and for many years did little by night and day but groan and shout in crescendo movement, box the walls so that his hands and knuckles were hard as horns, swollen, and often cut. He would often attack patients and attendants and officials violently. He was wonderfully rational amidst all this, saying he could not help it, that the steam would out. and that he had no desire to hurt any one or any feeling of revenge against any one. I have now a lady who is subject to paroxysms of acute mania, during which she screams in an unearthly howl, tears her clothes. bites her own hands, and will take your hand into her mouth and bite it a little all round, without really hurting you, if you will allow her. The third form, that, namely, resulting from a distinct morbid impulse to kill without conscious motive, I shall treat of more fully under impulsive insanity, the homicidal variety of which it is. with maniacal exaltation superadded. The fourth, or merely delirious form, is not really very dangerous, because it is purposeless and aimless, and the violence is not coordinated. It seldom is seen except when delirious patients are unduly controlled. A physician or an attendant in an asylum generally walks up to a PLATE VI. C HART. Showing the numbers per iOOO of Total admissions, and the A^es of 996 cases of Mania, 535cases of Melancholia, and 104 cases of General Paralysis, making together 1 635 cases of the 1778 Total cases admitted into the Royal Edinburgh Asylum in Five years. MANIA _______ MELANCHOLIA GENERAL PARALYSIS.... STATES OF MENTAL EXALTATION. 165 maniacal patient quite unconcernedly as to danger, thinking only of the symptoms present just as one would go in to see a case of pneumonia. PREVALENCE OF MANIA. The relative prevalence of conditions of mental exaltation is brought out by the fact that out of twenty-three hundred and seventy-seven cases admitted into the Royal Edinburgh Asylum in the seven years, 187480, thirteen hundred and ten, or fifty- five per cent., were classified as mania, while only seven hundred and twenty-nine, or thirty-six per cent., were cases of melancholia. The relative prevalence of the two conditions I have shown in Plate VI., which also shows the ages at which they prevail. Mental exaltation is there seen to prevail more at earlier ages than depression, and to occur most at two periods, viz., at the end of adolescence, and then about ten years afterwards. INSANE DELUSIONS IN MANIA. The most important thing to ascertain about delusions in mania is whether they are "fixed" or fleeting. A fixed delusion is usually the concentrated expression of a delusional condition of mind. I mean that it is seldom a patient merely believes that a person works an electric battery to annoy him. Such a delusion is generally the expression of an organic or nervous sensation of discom- fort or pain, which makes him have his natural suspicions heightened, he being morbid on other points. He will not trust any one. He is apt to think the air of his room or his food is poisoned. If the person whom he believes to be working this battery goes away, he will soon fix in his morbid imagination the same thing on another. A patient usually not only believes himself to be a king, but his whole state of mind is that of delusive grandeur. Such fixed delusional states, that last for more than a few weeks in mania, are unfavorable as to prognosis ; but do not put down either a single delusive fancy that is repeated consistently a few hundred times, or a delusive condition that merely lasts a few weeks, as a fixed delusion. The fixity of a delusion depends on two things the hold it has, whether it dominates the mental life, including other and natural mental acts ; and the time it has existed. Fleeting delusions are most typically seen in that delirium where nothing that is said has any relation to facts, and where no fancy or untrue statement is ever repeated twice. In very many cases of mania a delusion persists for a few weeks or longer, and yet passes away, and should not be counted a fixed delu- sion. There is no doubt that the less fixed and the more fleeting a delusion is, the better is the prognosis. Delusions take most various forms in mania. One of the most common forms is mistaking the identity of persons, calling them by wrong names, and recognizing old friends in persons never seen before. Certain kinds of insanity, such as the puerperal form, is specially characterized by this sort of delusion. INDICATIONS OF PROGNOSIS IN MANIA. The following are in my experience favorable indications in prognosis : A sudden onset of the disease ; a short duration ; youth of the patient ; no fixed delusions or delusional conditions ; appetite for food not quite lost ; no positive revulsion against or perversions of the food and drink appetites ; no indi- cation of enfeeblement of mind ; no paralysis or paresis, or marked affection of the pupils ; no epileptic tendency ; no complete obliteration 166 STATES OF MENTAL EXALTATION. or alteration of the natural expression of the face or eyes ; the instincts of delicacy and cleanliness not quite lost ; no unconsciousness to the calls of nature ; the articulation not affected ; the disease rising to an acme and then showing slow and steady signs of receding; no former attacks, or only one or two that have recovered. The effect of a strong and direct hereditary predisposition is not, as is commonly believed, sufficient to lessen the chances of recovery, especially from the first attack. On the contrary, hereditary cases are often very curable, but relapses are more probable. A brain so predisposed is more readily upset by slight causes. The following are unfavorable indications in prognosis : A gradual and slow onset, as if it were an evolution of an innate bad brain tendency e.g., if a naturally suspicious man has gradually become insanely and delusionally suspicious, or a naturally vain man has become affected with insane delusions of grandeur ; great length of duration of the attack, especially after twelve months' persistence of fixed delusions or delusional states ; extreme and increasing exhaustion of the patient, in spite of proper treatment ; paralysis of the trophic power, so that his body nutri- tion cannot be restored; persistent refusal of food, requiring forcible feeding ; extreme failure of the cardiac action and circulation, so that the extremities are always blue and cold ; persistent affections of the pupils, especially extreme contraction ; persistently dirty habits ; a tendency towards dementia ; a tendency towards chronic mania ; an utter and per- sistent deterioration in the facial expression, especially if it be towards vacuity ; persistent and complete paralysis or perversion of the natural affection and tastes and appetites ; many former attacks ; convulsive, paretic, paralytic, or incoordinative symptoms ; such perverted sensations as cause patients to pick the skin, pull out the hair, bite off the nails into the quick ; a restoration of sleep and bodily nutrition, without in due time an improvement mentally ; very persistent insane masturbation ; a tendency for the exaltation to pass off, and fixed delusion to take its place ; excitation of the limbs and subsultus tendinum ; a " typhoid " condition. TERMINATION OF MANIA. There may be said to be five usual termi- nations. 1. Complete recovery ; this takes place in fifty-four per cent, of all the cases of mania. 2. Partial recovery; the patient becoming rational and fit for work, but where there is a change of character or affection, or there is an eccentricity, or slight mental weakness, or want of mental inhibition, or lack of fixity of purpose, or a partial paralysis of the social instincts, or some inability to get on with people, or a lack or lessening of some mental quality which the patient possessed before. This is unfortunately a by no means uncommon result of an attack of any kind of insanity, but more especially of an attack of mania. Such persons count, of course, among the recoveries, and are reckoned legally sane. It is quite impossible to find out how many such cases there are, but I fear that at least one-third of all those who " recover " exhibit some such mental change as compared with their former sane selves. I think it is of the utmost importance to have the cure completed therefore, if possible, by prolonged medical care, by getting the whole bodily state, in regard to nutrition and nourishment, up to the highest possible mark before a patient returns to work or subjects himself to the causes of a STATES OF MENTAL EXALTATION. 167 relapse. It is the existence of this condition of mental change or mental twist so often, and the liability to relapse, that make the public suspi- cious of a man who has been insane ; through which suspicion great hard- ship and injustice are often done to those who have already suffered from one of the most terrible of human diseases. 3. The substitution of fixed delusions or delusional states (monomania) for the exaltation as the latter passes off. It is difficult to find out statistically how often this occurs. The patients may live long when this takes place, except the delusional condition be that of morbid suspicion, in which case they will probably die of phthisis within a few years. 4. Dementia supervenes. This happens in about thirty per cent, of the cases of mania generally. It is the event we most dread. It is equivalent to a mental death, while the body may live for many years, especially if the dementia has come on in youth. We have had many patients live so for fifty years in Morning- side. The bulk of the chronic patients in asylums are of this class. 5. Death occurs in about five per cent, of the cases from exhaustion, or from causes directly traceable to the disease. It must be understood that those are the terminations in cases of mania so severe as to require asylum treatment. If we could include the slighter cases treated at home, the recoveries would be more and the terminations in dementia and death fewer. PROPHYLAXIS OF MAXIA. A very important question often needs solu- tion by medical men in practice. There are young people growing up in the families they advise and attend with neurotic heredity, manifestly unstable brain constitution, " excitable " dispositions and nervous dia- thesis ; and the all-important question is asked, How can such persons best avoid the tendency to attacks of mania ? They have patients who have already had attacks of maniacal exaltation, some decided and some only nascent. How can such be avoided in the future ? If our present knowledge enabled us to answer these questions, no doubt there would be less insanity in the world than there is. We cannot do so surely, but we can do something in the direction of lessening the tendency of a brain to mania, I have no doubt. Beyond question, persons with this brain constitution should not enter on exciting and hazardous occupations. To take extreme examples, they should not be stockbrokers, election agents, or speculators. Quiet routine modes of life suit them best ; positions with fixed work and fixed salaries are most desirable for them. Much outdoor life, living according to rule, dividing up their day into regular portions for work and idleness and amusement. As regards diet, the same advice I gave about children predisposed to melancholia applies here. It should consist largely of milk and farina- ceous diet for the young. I lately saw a most excitable boy of six, very thin, restless, not sleeping much, and, of course, very bright and quick for his age. I found he was getting animal food three times a day, and his guardians deplored the fact that he could not take milk ; my advice was to starve him into taking it, to make him walk much and keep him out, and give him when he came in only bread and milk. Of course, it was disagreeable at first, but the boy soon acquired an appetite for such food, his bodily conformation largely changed, and he got fatter, less active, and slept far more. Children with this disposition are nearly 168 STATES OF MENTAL EXALTATION. always flesh-eaters, and I have sometimes found them fed on beefsteaks and port wine, with strong beef-tea between meals! I look on strong beef-tea drunk alone, without bread or potatoes, as simple poison for such children. I do not, of course, mean this to apply when they are ill, and need a stimulant. Such persons should take as much sleep as possible; they should cultivate quiet hobbies ; they should select country occupa- tions, and avoid stimulants, tobacco, and sexual intercourse till after adolescence. While ordinary well-constituted brains may stand excesses of all kinds, in work and in pleasure, and may even in a way be said to be sometimes the better for them, this is unquestionably not the case with those I am now describing. The excess of power beyond the daily needs, the capacity of quick recuperation, the tendency to stop working and to sleep when tired, the power of being satisfied with only a slight or an occasional excess over what the strict laws of nature would dictate, which characterize healthy well-constituted brains, are all wanting in those predisposed to maniacal attacks. I cannot help thinking that for such persons to take to study or to occupations that imply much brain- work is a risk, though they have often bright intellects. It seems to me as if instead of that they should go back to nature and mother earth, and become fanners and colonists. I once knew two brothers, twins, alike in mind and body, who had a strong heredity to mania. They both became medical students, and one had an attack of acute mania at twenty, which ended in dementia. At the beginning of his brother's attack the other had distinct premonitions of the same disease was sleepless, restless, unsettled, had queer sensations in his head, and felt as if he would lose his self-control. But he at once fled, as for his life, from books and brain-work, and went to be a land-surveyor in the Far West. His neurotic symptoms passed off, and he grew into a strong and happy man. I think it is the instinct of self-preservation that makes young men sometimes fly from the influences of civilization and take to the backwoods. But what about the young women ? Alas ! the prospect for those with such heredity, and when they are well off" and live in cities, is often lamentable. So far as my experience and observation go, the regulated life of a convent or sisterhood, or systematic religious and philanthropic work, fulfils the conditions of prophylaxis when the tendency is very strong, better than anything else. I am often profoundly impressed with the physiological and medico-psychological character of many of the observances and regulations of the Roman Catholic Church as to modes of life and outlets for the emotions. The framers of these observances had often anticipated modern physiological inductions. But suppose there is not merely a predisposition, but that the actual prodromata of the disease are showing themselves, let us say sleeplessness, want of full power of self-control, and general unsettledness, should medicinal hypnotics be taken opium, or bromides, or chloral, or henbane ? I think I have seen these do more good as sleep-producing prophylactics than as curatives after the disease had actually begun. There is no doubt that in the matter of its rest-in-sleep power, like many of its other faculties, the brain forms habits, and gets into bad and morbid as well as into good habits. A man falls off his sleep at his regular STATES OF MENTAL EXALTATION. 169 time or awakes at too early an hour, and he cannot get rid of this habit his brain has got or is getting into, and if allowed to go on uncorrected he will become exhausted and insane. Now, while I should in such a case invariably try first nature's simple sedatives sea or mountain air breathed all day, muscular fatigue, hot drinks at bedtime, change of scene and work, etc. ; yet I have to aid these often by a few doses of chloral and the bromides, or by a grain or two of opium at night. Camphor and tincture of lupuline are often sufficient sedatives, or a few drops of tincture of belladonna, in fact any sleep-producer; but do not, if possible, let the brain get into the evil habit of depending on such drugs for sleep. LECTURE V. STATES OF ALTERNATION, PERIODICITY, AND RELAPSE IN MENTAL DISEASES (FOLIE CIRCULAIRE, PSYCHORYTHM, FOLIE A DOUBLE FORME, CIRCULAR INSANITY, PERIODIC MANIA, RECURRENT MANIA, KATATONIA). ONE of the most fundamental of the laws that govern the higher functions of the nervous centres in all vertebrates is that of alternation and periodicity of activity and inactivity. In all the higher species of the class the periods of inactivity are marked by unconsciousness, and are often combined with the mental phenomena of dreaming and muscular expressions or equivalents of ideation ; which things are quite as strange and inexplicable in their essential nature as the phenomena of mental disease. Both may be in a general way understood by reference to men- talization as a brain function. Neither are in any way comprehensible on any mere mind theory apart from brain. The sleep and waking periodicity of the higher brain functions is the foundation and type of all the other periodicities which exist in the nervous functions, and they are not a few. The yearly hibernation of many animals, the daily periodic rises and falls of body temperature, the daily increase and decrease of the pulsations of the heart and of the cardiac pressure, the periodic returns of the appetites for food and drink, and of the activities of the glands and involuntary muscles through which food is digested and assimilated, are all examples of secondary nervous periodicities which occur in the course of the daily life of the organism. When we look at the function of reproduction of the organism, we find that every activity and process is subject to laws of periodicity of the most marked character ; and there can be no doubt that these all have their origin in the brain. The period of reproductive activity is always, in both sexes, the period of greatest physiological mental exaltation. The periodic rutting season in male animals, with its courage, pride, activity, display, pugnacity, and restlessness ; the young-bearing and suckling period in females, with its increased courage, skill, cunning, protective and providing instincts, show how the functions of the brain are affected by the reproductive perio- dicity. So much are they affected that the mental characteristics of some animals are completely changed from their natural condition and reversed, the timid becoming bold and the shy obtrusive ; hereditary and natural antipathies and fears disappear for the time, the habits change, night- feeders become day-feeders, etc. We should not approach the study of the periodicity of symptoms in nervous and mental diseases without keeping in mind these laws and facts of the physiological periodicity of normal nerve function wherever we have a higher nervous system. Looking at the mental activities of human beings, we find them STATES OF MENTAL ALTERNATION. 171 strongly influenced by the physiological periodicities. What man is there who is not emotionally more elevated or depressed, more active or inac- tive in mind, at certain times, or at his periods of almost regularly re- curring reproductive desire and capacity ? What woman is exactly the same in mind before, during, and after menstruation, and during preg- nancy or lactation ? And the instant we pass from absolutely healthy brains, all those periodicities count for more in the mental life, their effect in dulling, elevating, and depressing being far greater. There are thousands of sane men and women who are regularly duller in the morn- ing and more lively in the evening, or the reverse ; or who are duller in the winter and more elevated in the summer ; or who are more irritable that is, have diminished inhibitory power at periodic intervals, or who are subject to "moods" and "tempers" periodically. There are many persons whose mental life is one long alternation of "action" and "re- action," activity and torpor, by a natural law of their organization. When we look at diseases of the nervous system other than the mental, we find that many of them are often markedly periodic in their symptoms and times of recurrence. I need only instance neuralgia, migraine, and, above all, epilepsy, that motor analogue of many mental diseases. Two French writers, Falret and Baillarger, were the first to describe as a special form of insanity -certain cases in which there are regularly alternating and recurring periods of mental exaltation, depression, and sanity, and to call it folie circulaire. Each of these periods may vary in absolute duration from a day to several years, and in relative duration to the other conditions in the circuit in different cases ; but they always recur and follow each other with more or less regularity. In some the period of exaltation is long and the depression and sanity short ; in others this is reversed. But in the really typical case the periods are each about the same length in each psychological circle, and the recur- ring circles all about the same size. Usually there is something special about the exaltation and depression. The exaltation is very pure brain exaltation, with often hyperaesthesia and exaltation of many of the ner- vous functions, with much reasoning power left, but little self-control or common sense ; the condition described by the French as folie raisson- nante, or Pritchard's moral insanity, being well marked at the early stage. There is in nearly all the cases great increase of the reproduc- tive nisus. The phases of the exaltation, down even to small things, recur regularly in different attacks at the same time. The depression is apt to be characterized by apathy and torpor rather than by intense mental pain : there are seldom any strong suicidal feelings or impulses. And the period of sanity is apt to be a sort of stupid, inactive sanity, wanting in volitional power, full affectiveness, and spontaneity. The mental balance goes on oscillating between melancholia and mania, standing still at the happy mean of apparent sanity just long enough to raise hopes that recovery has taken place for a few times, till the nature of the disease is apparent to the physician, and as often as they occur to ever-hoping relatives. It is mostly an incurable disease, and the bad cases are usually sent to asylums rather than treated at home. The interest of this form of mental disease is small when it is merely looked at as a rare psychosis of typical form ; but it is very great indeed 172 STATES OF MENTAL ALTERNATION. to the student of psychiatry when, in the first place, we make it a means of studying the clinical differences in the whole brain and body state of the same patient in exaltation, depression, and sanity respectively ; and when, in the second place, we look on it as a pathological illustration of the great physiological periodicities to which I have referred, and of the almost constant tendency there is in nearly all cases of insanity, or at least in most of those that are hereditary, towards relapse, alternation, periodicity, or sympathy with exalted physiological function. The following are some illustrative cases : D. A., set. 49 on admission to asylum. He had never been placed in a hospital for the insane before, though he had had from his boyhood dull times and active times, and many slighter attacks of the kind I am about to describe for five or six years previous to his admission. In one of the periods of exaltation, while holding an important position in India, he had got two tiger cubs, and tried to drive them in harness through the streets of the Residency. His education was good, his temperament sanguine. He had been reckoned proud and retiring, and he was of an old and distinguished family. In bodily conformation, carriage, and bearing he was the type of an aristocrat. A paternal uncle, at least, had been insane, and had shown periodicity. His family had been a very artistic one, but he had never, when sane, shown any talent in that way. He had married and had children. Just before admission he had been spending money recklessly, pro- posing marriage to many suitable and unsuitable persons, getting into passions and using threats about trifles, reckless, eccentric, changeful as the winds in intention and execution. The attack was coming on, but had not come to a height till a week after a domestic loss. When admitted he was much excited and very indignant, calling on all to witness that he was illegally imprisoned, threatening the dire vengeance of the law on all who had to do with it, but in about ten min- utes he was quite jolly, and amusing himself with a game of billiards. At first he was exalted mentally, but had much self-control. His ex- citement consisted in a constant restlessness, a perpetual twisting move- ment and play of his facial muscles. He could not sit still, or read, or engage in a game for long. He talked much, but could not stick to one subject ; he was boastful in a way that was to him unnatural ; he spoke of his private aifairs, and would indulge in very pointed questions and remarks, without much regard to your feelings. To a good billiard- player, " I'll give you fifty points, and bet a pair of gloves I'll beat you. I don't want to hurt your feelings, but I suppose you know your style of play is not very fine." To a man who had been in trade, "What do you think of my stockings, Mr. ? That was in your line." He was often extremely amusing, fluent, and witty, which he had never been when well. He would rattle off Scotch to the pauper patients in the grounds, French to the ladies, and Hisdustani to himself in a way he could never do when sane. In dress he was untidy, and in habits dirty. To the ladies, of whose society he was extremely fond, he was exagger- atedly polite, with the grand air of the olden time ; but if they gave him any encouragement he would soon become too familiar. He was always giving them flowers, which he had stolen, and writing them notes, or STATES OF MENTAL ALTERNATION. 173 trying to kiss the maid-servants. If he had any request to make from a lady in the drawing-room, it was no uncommon thing for him to go down on one knee, with his hand to his heart, and all this done most gracefully and amusingly, as if half in fun and much in earnest. He smoked as much as he could get, and was always grumbling he did not get cigars and tobacco enough, and begging, borrowing, or stealing more. He ate enormously, but not nicely, of everything that came in his way. He picked up and appropriated everything belonging to others that he had a fancy for, and did this also most gracefully, as if it was the most natural thing in the world. He was irritable when controlled, contradicted, or refused requests, and he was always making innumerable and impossible requests. He slept badly, and would, if allowed, sit up all night, or get up and move about by three or four o'clock in the morning. He was not susceptible to cold, sitting with all his windows open in winter. He passed gradually out of one stage into another. The next stage was a more maniacal one. He dressed more grotesquely, and always wanted to put on three or four coats, vests, or trousers on the top of each other. He would come in to a dance with four vests, would go behind a door or another man, and slip one and then another off as he got warm. His habits and ways got more dirty and disorderly. His irritability took violent forms, assaulting his attendants, smashing furniture, etc. His conduct became so uncontrolled that he could not go to the drawing-room or to church. He would run after a petticoat without regard to the ap- pearance or age of its wearer. His whole tastes as to food were the op- posite to what they were in health. He liked porridge, which he could not abide when well, and if he did not feel inclined to take it, he would turn it out on to his newspaper, put it in his pocket, and eat it when he felt hungry. He Avould mix up soup, milk, and claret, and eat them together. Scarcely anything was incongruous or disgusting to him. He wore his hair very short, and would singe it or cut it himself if he could get no one else to do it. He would, in playing cricket, strip him- self almost naked, or put on the most ridiculous things, a woman's hat or shawl, or a cap turned outside in. He turned up at morning prayers one day in buckskin tights, a red vest, a blue cap, and black swallow-tail. His bowels were always moved twice or thrice a day. During all this time he was losing or tending to lose weight is spite of all he ate. He had his better and worse days all through, usually in alternation. He used to paint and draw pictures and portraits at this stage, producing the vilest daubs, spitting on the paper to moisten his colors, and using his hand and fingers to spread his paints. These he would carry in his pocket by the dozen, showing them to any one he met and he could pass no one without speaking. He said he had never known he could paint before. So with singing : he would sing in discord, and think he was doing splendidly. Yet with all this there never left him a certain jauntiness and grace of manner. No one, at his worst, could have taken him for anybody but a high-bred gentleman. As this brain exaltation came on and increased in every successive attack, each little phase, each little morbid way, such as smoking, eating certain kinds of food, cutting or singeing his hair and beard, painting, 174 STATES OF MENTAL ALTERNATION. putting on one coat on the top of another, would recur with the regu- larity of the bud, leaf, and fruit of a tree. The next stage was the gradual subsidence of all these symptoms of maniacal exaltation, and a resumption of his former habits and ways and appearance. The first stage, corresponding to simple mania, lasted for about a month ; the second, with the symptoms of mild acute mania, about two months, and his recovering stage about three months, so that the whole period of exaltation lasted six months ; but he did not stop at the sane stage. He at once passed into a condition of great mental depression. To see him in that, one would scarcely have known him to be the same man. His hair well grown, his whiskers trim, his features and eyes dull and inexpressive, his dress most scrupulous and neat, his manner distant and nervous ; in speech reticent, and never venturing a remark ; in feel- ing depressed, fearful, and unreliant. He thought he was so wicked that he should not see any one. He now disliked most of the people he had cultivated during his exaltation, especially relying on the chief at- tendant, who had controlled him most, and whom he had most heartily abused. His habits were sedentary, he could scarcely be got to go for a walk ; his appetite was now moderate, and his tastes very particular, not being able to bear the smell of tobacco or to look at porridge or messes of any kind, and most sensitive to dirt and bad smells. He became very penurious about money. He was always thinking he was doing wrong or giving offence, and did not like company, while he was most moral and religious in his feelings and habits. His whole intellectual and affec- tive life was far more unlike his exalted self than one average man is unlike another. He was stationary in weight at first, but soon began to gain. He was most sensitive to cold and draughts and loud noises, in all of which he had delighted before. He was full of a morbid sorrow and regret for his previous conduct ; but he was morbidly suspicious at this stage, and used to think that the things he had given away or destroyed during his excitement had been stolen. This condition lasted for about three months, gradually passing into one of complete sanity, without de- pression or elevation, but with some inertness at first, and without much capacity for business. This lasted about six months, and then the signs of elevation again began. Altogether this circle of elevation, depression, and sanity lasted about fifteen months. There was no marked line any- where, though the most distinct and sudden transition was between the elevation and the depression. The development of the exaltation next time was a slow process, taking about two months before it got so bad that he had to come back to the asylum. The sort of things he did were going out to ride at 10 o'clock P.M., never going to bed, smoking all the time, foolishly wasting his money, proposing to marry ladies and women suitable and unsuitable, sometimes two in a day, telling one, as an inducement to accept him, that if she would marry him she could put him into an asylum and enjoy his pen- sion ! He went into a shop to buy a pair of gloves, and the shop-girl taking his fancy, he went down on his knees to her, telling her he had fallen in love with her. His nisus generativus was always exalted during the excitement, but seldom assumed very gross forms. He often said STATES OF MENTAL ALTERNATION. 175 that if he could be castrated he would be cured. The great difficulty at this stage was to get " facts " indicating insanity to put in the medical certificates for his admission to an asylum, for he was very acute, and knew what a doctor's visit meant quite well ! In the second circle of his disease after coming to the asylum, all the symptoms were similar to the first, and developed themselves in the same order. The excitement was more acutely maniacal than it ever was before or has been since. The whole period of elevation lasted a year this time, of depression six months, arid sanity six months, the circle taking two years to get through. The third circle had a period of excitement of ten months, of depres- sion of six months, and of eight months of sanity in all, two years. The fourth circle had a period of excitement of thirteen months, of de- pression of about six months, and of sanity of fourteen months in all, two years and nine months. He was out of the asylum, living at home, for a year and eight months during part of the depression, the whole period of sanity, and the first month of the commencement of the ex- citement. He did not enjoy the society of his relations during the de- pression, and they said he would have been better to have been in the asylum ; and at the beginning of the excitement, when they had to re- monstrate with or control him, his affection for them ceased, and he got on worse with them than in the asylum with strangers. He said cruel and unkind things to them. In the fifth alternation the excitement lasted two years, the depression twelve months, and the sanity fifteen months the whole thus taking four years and three months. He is now in the twenty-third month of the exalted stage of the sixth circle, with the usual symptoms, but none of them are so severe as they were on previous occasions. It seems as if, at sixty-two, his brain was not capable of taking on so acute an attack of excitement, the nisus generativus not being so keen. He is now capable of being sooner tired, and takes rest, which he never did before, and the diurnal changes are very marked. He has one good and then a bad day. But the outward eroticism, the alertness and grace of move- ment, the kleptomaniacal tendencies, and all the small phases of his ex- altation are still there, there being no trace of the mental enfeeblement of dementia, of bodily exhaustion, or of chronic mania. The damage done to the organ by the previous attacks of exalted morbid energizing has evidently been repaired in the intervals of sanity, during which he lays on flesh greatly. The bromide of potassium alone and combined with cannabis indica did not influence any of the attacks of excitement. The following is the record of a case of most prolonged, and, on the whole, one of the most regularly alternating cases of folie circulaire in short circles I have ever seen: D. B., set. 30, was admitted to the Royal Edinburgh Asylum in 1847 without any history whatever ; but she was a person of education and intelligence, though sent as a pauper patient. She labored under all the symptoms of acute mania at first, and in a few days it was recorded that she was "imbecile," then in a few days more that she was quite well. Since that time till now for thirty-six years she has had regularly recurring short attacks of acute mania, during which she is restless, 176 STATES OF MENTAL ALTERNATION. incoherent, excited, destructive to her clothing, violent, and with no memory or consciousness of familiar things or persons, this lasting from a week to four weeks usually. This is succeeded by a few days of a con- dition with all the symptoms of dementia with a little depression, and she then becomes practically sane for a period of from a fortnight to eight weeks. Her circle takes from four to twelve weeks to complete, enfeeble- ment of mind taking the place of the more usual depression. We have a. wonderfully complete record of her symptoms all these thirty-five years ; and though once or twice there are such entries as " She is now almost continuously excited," as in 1852 for a month or so, or "Periods of excitement more frequent, of quiet shorter," as in 1853 and in 1861, "Intervals of quiet longer," as in 1862, yet the irregularities are no greater than are common in regard to menstruation in the average woman. There can be no doubt that this is an example of mental alternations governed in their times of occurrence and duration by the menstrual periodicity. For long she had amenorrhoea, but the return of the catarnenia made no difference, and, more strange, the ceasing of men- struation at the climacteric made no difference. Now, at sixty-six, the regular alternations of acute exaltation, mild stupor, and sanity are not so regular as before, and the symptoms of the exaltation are scarcely so acutely maniacal as at first. The whole case is otherwise instructive, for though it shows the known tendency in a brain for acute excitement to exhaust and destroy the normal power of energizing of the convolutions and leave that diseased mentalization which we call dementia, it also shows this, that even severe attacks, when short, produce only a short enfeeblement, which is recovered from soon. Most instructively of all, it shows that over two hundred of such attacks, continued for such an enormously long period as thirty-six years, need not necessarily destroy the mental power of the brain and produce complete and permanent dementia. The brain in this proves the recuperative and resistive power that it shows in many other ways, if the periods of the exalted energizing, or the strain, or the poisoning, or the morbidness is only short in time, and the organ gets rest between one attack and the next. We all know that periodic sprees may be continued with impunity ia many people for a lifetime, and that many men may safely work their brains at full pressure for many years if they give them a Sunday rest and an annual holiday. I had another case, a lady, D. C., who was for ten years in the asylum, who took attacks of excitement lasting about a fortnight alternating with periods of depression for a week, but in her case, as in that of D. B., the depression immediately preceded the excitement, and the periods of sanity were about three weeks in duration. But, like all the rest of the cases, the length of the periods of the different conditions was not abso- lutely uniform. In her case, also, the regular alternations went on up to the age of seventy-eight, when she died ; occurring only in a mild form during the last six months of her life, when she had a broken leg, an ulcerated and sloughing ankle, and was very exhausted. But her mind was rather enfeebled during the quiet "sane" periods for the last ten years of her life, and she had 'sexual delusions about men wanting to .seduce and marry her. The exhausting effects of the excitement on her STATES OF MENTAL ALTERNATION. 177 brain, as in many of the alternating cases, were aggravated by her addiction to masturbation during the exalted periods. I have noAV under my care a gentleman, D. D., aged 49, who for the past twenty-six years has been subject to the most regularly recurring brain exaltation every four weeks almost to a day. It sometimes passes off without becoming acutely maniacal or even showing itself in outward acts ; at other times it becomes so, and lasts for periods of from one to four weeks. It is always preceded by an uncomfortable feeling in the head and pain in the back, a mental hebetude and slight depression. The nisus generativus is greatly increased, and he says that if in that condition he has full and free seminal emission during sleep the excite- ment passes off; if not, it goes on. Full doses of the bromide and iodide of potassium have the effect sometimes, but not always, of stopping the excitement, and a very long walk will at times do the same. When the exaltation gets to a height it is followed always by about a week of stupid depression. It seems as if the depression in those cases always meant a reaction after morbid over-action a muddy mental calm after a storm, an anaesthesia after a hyperaesthesia. In the following case the alternations began in old age : D. C., set. 74 on admission, unmarried, has had several attacks of excitement in the three years previously. A sister is insane, and brother hemiplegic with periodic attacks of mild mental exaltation, which also came on in advanced life. But the patient had been a staid, industrious man, who had been in business all his life, and done his work well till he was over seventy, leading a sober life. He has been excited for three months. It began first by great mental exaltation and hilarity of manner. He was very fond of the ladies, but never erotic. Especially he used to laugh most immoderately at nothing in particular, putting down his stick into the ground, and bending forward and roaring with laughter from five to ten minutes running. This had exactly the effect of a man laughing well and continuously on the stage, at a cause of which you are ignorant ; it was catching, and you could not help laughing too. This gradually passed into a stage of violence, delusions of insults, shouting, sleeplessness, and suspicion. During the exalted period his temperature was always over 99, he ate enormously, craved stimulants, his bowels were moved twice a day, and he slept little. His conduct was extremely ridiculous for an old man. His delusions were mere fleeting fancies and suspicions. In four months from the beginning of his attack he became depressed, and then he never spoke, looked dull and heavy, slept well, and got fat, but his bowels became very costive. All his brightness and curiosity and much of his intelligence left him. He took no interest in anything. There was much of stupor in his state. He felt little mental pain. After about two months he got over his dulness, and became practically sane, cheerful, chatty, and contended. After three months of this condition, or about nine months from the beginning of the attack, he gradually got exalted, and passed through exactly the same phases as before. One never gets pure mental exaltation so well as in a good case of alternating insanity. The excitement lasted about six months, from March to December, being very mild for the last three months ; he then passed into a two months' attack of stupid depression as before, and 12 178 STATES OF MENTAL ALTERNATION. was then fourteen months well, his whole circle thus taking twenty-two monihs to complete. He next got exalted in December, and was acutely excited for about three weeks only, and then had an attack of extreme stupor, depression, weakness, and prostration for three months. He then became sane ; but almost at once passed into another attack of excitement. The whole duration of this circle was only four months. The excite- ment that followed was moi'e acute than it had ever been before ; it lasted five months, and was followed at once by great, depression lasting six months. He was then sane for three months, this circle taking fourteen months to complete. This time he became exalted in May, and Mr. Geoghegan, the assistant physician in charge, thus describes him : "Mr. I). C. is abnormally excited and emotional. When in good humor he is ridiculously polite, tells the most pointless story over and over again, laughs louder and harder at it each time it is told, till the tears run down his cheeks and he has to hold on to some object to prevent him from falling ; and his listeners, by pure contagion, are in much the same con- dition. At other times his conversation is absurdly religious, and he overdoes the part of a sanctimonious revivalist; and if his hearers show any want of gravity a hard thing to avoid he gets passionately indig- nant, and after a storm of displeasure goes off in high dudgeon. He can never bear contradiction or difference of opinion without anger." This circle took twenty-one months to complete. In December he became exalted again, his irritability being very great this time, and his hilarious happiness less marked. He remained so for nine months, and then became depressed rather suddenly, passing into a condition of almost complete stupor, and leading an almost vegetative life. He remained so for almost five weeks, and then, without the usual intermediate period of sanity, he suddenly one night became delirious with hallucinations of sight, but this only lasted for one day. He was then four days depressed, and again got exalted, with more decided delusions than he had ever had before. This lasted less than two months, and he then went into an attack of stupor again. By this time he was eighty-two years of age, and he had an epithelioma of one of his great toes, with irritation and suppuration, which acted as a drain and an irritant. This toe was ampu- tated by Mr. Bell, and he made a good recovery, and he gained in flesh and strength, but has remained in the condition of depressed partial stupor ever since for three years, lying in bed mostly. He will answer questions when spoken to, but never ventures a remark or takes any notice of anything. He is in a state of complete senility and mental torpor. In this case, as in most of the others that I have seen with prolonged alternations, they were irregular ; but in him the periods of excitement always began in cold weather, from October to May. The most striking circumstance about the case is its commencement at seventy-four, after the intensity of the sexual period of life was past. It is only the second case of that kind I have known. The excitement coming on in spurts for a few days at the last, as if the senile brain had no longer vigor enough to keep up a prolonged exaltation, would seem to be the natural ending of alternating insanity, whether it terminates in mild or complete senility, or in dementia. STATES OF MENTAL ALTERNATION. 179 In the following case of D. B., the attacks of excitement and those of depression ceased at the age of sixty-five, after alternations of the two had lasted for twenty years. He was an artist, but could only paint at the beginning of the period of exaltation and at the end of it. He never could finish a picture, and if he attempted to do so he got worse mentally. So long as painting was spontaneous or pleasurable he did it, and it did him no harm. If he could not catch a likeness, or tried to elaborate or paint in details, or had nothing but drudgery to do, he got worse. In his case there was most marked exaltation of the memory, and his fancies always took the pleasant form of a loss of his own personal identity and the assumption of that of the author whose works he was reading or repeating. As he got better he would tell me that he was very happy indeed as he lay awake at nights, for he would fancy he was Shakespeare, Burns, or King David, as he repeated aloud their works. He could vividly recall the events of his boyhood, and repeat long con- versations he had held with his friends then. His eyesight and hearing became very acute, so that he could read small print, and paint without spectacles, and hear whispers ; while as the exaltation wore off he had to use stronger and stronger spectacles, and was very deaf. When depressed, all his bodily functions, appetites, and propensities were torpid and sluggish. There was a difference of 2.2 between his average temperature during exaltation and depression. There is in the case-books of the Carlisle Asylum a careful record of his condition from 1862 till his death in 1876. ML 54, 1862, January, exalted ; July, pretty well : 1863, July, quite well ; October, depressed : 1864, February, exalted ; July, depressed ; October, quite well : 1865, April, depressed ; August, exalted: 1856, January, quite well, and remained so till 1867, when in July he got depressed, and in December his alternations were diurnal, he being one day depressed and the next very excited, this lasting for a month or two : 1868, July, became depressed ; October, quite well : 1869, April, depressed, and was so till October, when, instead of the usual and expected exaltation, he got quite well, and kept so for over three years, till January, 1873, when he had a short attack of mild exaltation, lasting for three months. He then kept well till January, 1874, when he had a few occasional days of slight excitement at irregular intervals, and then got quite calm and rational, though not energetic in fact, he got into the typical and normal senile condition of mind and body, his brain remaining in this quiet haven of rest, after its twenty years of violent alternations of storm and sluggishness, till he died of bronchitis in the end of 1876, at sixty-eight. In this case it will be observed that there was a distinct tendency for the periods of exaltation to occur in the early part of the year, in January and February, and the periods of depression to come on towards the end of the year, from October to December. The periods of depression did not follow, but precede, the exaltation in this case, contrary to the usual experience. One should perhaps say that the excitement followed, and seemed to be a reaction from the depression. The following dates of the admission and discharge of D. I. show the length of the attacks in his case, for he is sent to the asylum whenever he gets exalted, and is sent home when the excitement passes off. He is then 180 STATES OF MENTAL ALTERNATION. not very painfully depressed, quiet, penurious, and unsocial, sluggish for two or three months, and then gets quite sane and does his business very well. His exaltation is of the typical kind, talkative, energetic, passionate, quarrelsome, abusive, restless, sleepless, but never incoherent, and very fond of spending his money lavishly. He once got off to London about the beginning of an attack with 1000 in his pocket, with the deliberate intention to spend it in a month and enjoy himself, as he said he had "led too quiet a life at home," and he pretty nearly got through it. I have reason to believe that he once made a large sum of money during one of his exalted brilliant periods, just as he was passing into the elevated part of a morbid mental circle. Hopefulness, superabundant energy, mental subtility, argumentativeness, wildness, a strong leaning towards the other sex, but not an offensive eroticism, characterize this period. The dates show the irregularity of the seasons at which the attack came on, and of their duration. He was forty -five when first admitted, and had had a few attacks previously. Admitted October, 1866, discharged January, 1867 ; admitted April, 1870, discharged May, 1870 ; admitted August, 1871, discharged September. 1871 ; admitted December, 1872, discharged February, 1873; admitted February, 1875, discharged May, 1875; admitted August, 1877, discharged September, 1877 ; admitted Novem- ber, 1880, discharged January, 1881; admitted December, 1881, discharged March, 1882. An examination of the exact periods during which the exaltation, depression, and sanity persist, their relation to each other during different recurrences, and the sizes and regularity of the successive circles in each case, shows this far more than I had supposed previously to more exact investigation, viz., that the periods are not always the same in the same patient at different times, and that, in fact, very few of them are regular and typical in their symptoms. I only find about one or two out of forty cases of folie circulaire that were absolutely regular. In others the periods of excitement were often twice as long in one circle as in another, and the periods of depression and sanity varied also. The age, state of the general health, conditions of life, critical periods, diet, medicines such as combination of the bromides and Indian hemp, have all the power of modifying the length and the intensity of the periods of exaltation particularly. We shall see how important those facts are, taken in conjunction with the views as to the essential nature of those alternations which I am to speak of. While a typical case of alternating insanity is not hopeful, yet, in prognosis, we must not conclude that a case is incurable merely because there are recurrences and alternations for a few months or for a year, or even for two or three years. It is very interesting and most important to study minutely the ex- act psychological differences in the same brain when morbidly elevated, and depressed, and sane ; and it is almost equally important to compare the differences in the bodily symptoms of the two former conditions. The cases I have recorded show many of these differences and symptoms. In the elevated stage, either at the beginning or all through it, there is an actual exaltation of many of the mental faculties, notably of memory, of general acuteness and ability to reason, in a way. The mentalization STATES OF MENTAL ALTERNATION. 181 is almost unceasing in some form ; the common-sense is gone ; the power of self-control and of undertaking definite mental work is gone ; the power of attention, while it may be very acute in some ways, is not under the control of volition ; there is a childishness of mental condition in some respects, a foolish credulity ; affectively the patient, though he feels morbidly happy, yet his emotions are always shallow and directed in fits and starts only towards objects and persons that are present, and they are always weakened towards or withdrawn from their natural objects, wife, children, etc. There is a most remarkable change in the appetites, which are usually quite perverted from what was natural to the patient. Different kinds of food, drink, and stimulants are sought for and enjoyed. The general feeling of bien-etre is exaggerated. The courage is exag- gerated, and there is little timidity left. There is an intense desire to attract attention. There are always extravagance and morbid generosity. The social instincts are enlarged, lowered in tone, and they become some- what promiscuous, a man nearly always seeking the company of his in- feriors in station. In the stage of depression the natural affections towards children usually return or flow into their natural channels with much force, but the subjective feeling of the patient is one of misery and ill-being : he has no courage, no power to resolve, no general activity of mind. In all the typical cases there is a sort of torpor and inactivity of mind ; there is niggardliness in money-spending, in wearing clothes, etc. There is often a feeling of profound disgust and regret at the extravagant, foolish acts of the excited period. The changes in the bodily symptoms are very marked. The patient, when exalted, loses weight ; when depressed he gains weight ; the differ- ence in weight between the two periods being often two stones. When excited he takes much exercise, is restless, and never tires. When de- pressed he is sluggish, and dislikes exercise, and is soon tired. In the former stage his temperature is above the normal, especially in the even- ing ; in the latter below it, the average difference being 1.1, and in some individual cases 3.6. In the former he can bear cold well, and likes it ; in the latter he cannot bear cold, and dislikes it much. In the former his bowels are very regular, and often moved more than once a day ; in the latter they are costive. In the former his face is mobile and expressive, and his eyes glistening ; in the latter they are heavy. In the former he is always hungry, and his capacity for eating and digesting everything almost unlimited ; in the latter he may eat well, but is very particular as to food. In the former he craves stimulants and tobacco ; in the latter he often loathes them. In the former he is not sensitive to disagreeable odors, sounds, and sights ; in the latter he is usually hyper- sensitive. In the former the skin is moist and perspiring ; in the latter it is usually dry and often hard, and skin diseases, such as psoriasis, not infrequently appear. While exalted, the patient's pulse is usually full and hard ; while depressed, small and compressible. In the former the sexual appetites and capacity are always increased ; in the latter they are often paralyzed. (One gentleman to'ld me that for two years he had no sexual feeling or power.) The sight and hearing are often much more 182 STATES OF MENTAL ALTERNATION. acute- in the former than in the latter. In the former state the patient sleeps little and lightly ; in the latter long and soundly. Many ordinary nervous symptoms follow the periodicity and alterna- tion of the mental. I had one woman Avhose circle took about six weeks to complete, and whose period of elevation was always preceded and ushered in by severe cephalalgia and then by vomiting. I have had several women in Avhom the depressed period was preceded by neuralgia. Several of my patients can tell beforehand when they are going to get excited, by their bodily feelings. One form of alternation has been called Katatonia by Kahlbaum. It is an alternating insanity, in which there are either epileptiform symptoms or those resembling catalepsy, hallucinations of sight and hearing, unconsciousness, with trophic symp- toms, such as oedema and weak pulse, these preceding or accompanying the melancholic stage. It is simply a variety of the disease in which the functions of the motor and trophic centres are specially involved. I have for a long time been impressed with the relationship of the mental and bodily alternations and periodicity in insanity to the great physiological alternations and periodicities, and I have gradually been led to the conclusion that they are the same in all essential respects, and only diflFer in degrees of intensity or duration. By far the majority of the cases in women follow the law of the menstrual and sexual period- icity; the majority of the cases in men follow the law of the more irregu- lar periodicity of the nisus generativus in that sex. Many of the cases in both sexes follow the seasonal periodicity, which perhaps in man is merely a reversion to the seasonal generative activities of the majority of the lower animals A careful clinical study of mental diseases reveals the fact that there exists in by far the majority of all the acute cases, at some time or other, in some form or degree, in the course of the disease, a tendency to alter- nation, periodicity of symptoms, remissions, or recurring relapses. I have taken the 338 cases of mental disease admitted to Morningside Asylum in 1881 181 of them being cases of mania, and 129 of melan- cholia, the rest being general paralysis, dementia, etc. and I find that in 81 of the female cases, or -46 per cent, in that sex, and in 67 of the men, or 40 per cent, of that sex, there was relapse, alternation, or periodicity of symptoms in the course of their attacks. Many of the 338 admissions were chronic on admission, so that of the recent cases the decided majority showed those symptoms. 50 of the 129 cases of melancholia, or 39 per cent., and 98 of the 181 cases of mania, or 54 per cent., were alternating or relapsing, or showed diurnal, or monthly, or seasonal, or sexual periodicity. It may therefore be concluded that insanity in the female sex has more of this character than in men, and that the cases of mania have it to a greater degree than those of melan- cholia. In some patients it was a morning aggravation and evening im- provement, those being usually cases of melancholia ; in a few it was an evening aggravation, those being, contradictorily, also cases of melan- cholia. Very many cases of mania were more exalted one day and less BO the next ; many sleeping and waking on alternate nights, these being usually cases of mania. The attendants are very strong on this point of the "good" and "bad days" of these patients, and calculate much on STATES OF MENTAL ALTERNATION. 183 them. Many of the cases had remissions and relapses of a few days regularly for a time. Some had monthly or menstrual aggravations. In some cases these periodic remissions occurred most at the beginning of the attack, but in far more cases towards the end of it, and during the convalescence of the patient. I had a lady lately under my care, con- valescing from acute mania E. K., a strong, healthy woman of 38, who had recently recovered from a bad attack of rheumatic arthritis. First attack, duration ten days. Heredity to insanity. She remained in a state of acute excitement for about a Aveek after admission, getting, however, at intervals sufficient sleep and sufficient nourishment. An abatement of the disease then set in, and from that period there was a slow but steady improvement until seven weeks after admission, when she was discharged, having made an excellent recovery. The most striking feature in the case, during the latter weeks of its course, was the distinct daily morning exacerbation and evening remission. Each morning showed a distinct improvement on the previous morning, but a distinct relapse as compared with the previous evening, while each evening she appeared to be further on the road to recovery than she was the evening before. In the morning she would be full of doubts, suspicions, and querulousness, while the evening would find her sensible, cheerful, and grateful. The change would corne on in a few minutes without external cause. Even when convalescence was well advanced, the morn- ing was for her a period of distress and distrust, but with the evening came quiet, rest, and a thankful heart. Such a case is merely a type of what is very common during all forms of mental disease, especially during convalescence. A medical man in attendance should always prepare the minds of relatives for this tendency to relapse and alternate. Nothing is more discouraging to both the doctor and the relations, when it persists for a long time ; but it is our duty to keep up their hopes and ours, and to think of, and refer to examples where the tendency has been quite got over, even after a long time. I once had a young man of twenty who took regular relapses for five years, and after that made an admirable recovery, and to my own knowledge has done his work well and has kept well for ten years. Taking the chronic incurable cases now in the Asylum, I find that about forty per cent, of them are subject to aggravations of their diseases at times. I find that the younger the patient the greater is the tendency to periodic alternation, remission, and relapse. The phenomenon finds its acme in the cases of pubescent and adolescent insanity. I also find that the stronger the heredity the greater the tendency to periodic relapses and alternations. I have never met with a single case that could be called typical folie circulaire where there was not hereditary predisposition to insanity. It seems as if there were certain brains so constituted as to be incapable of energizing except irregularly, swinging between elevation and depression, like a bad electric light. The above facts and statistics refer to ordinary remissions ; but the infrequency of cases with such regular and continuous alternations as to be properly called folie circulaire may be seen from the fact that out of eight hundred patients in the Asylum at Morningside now there are only six- 184 STATES OF MENTAL ALTERNATION. teen of this kind, or two per cent., and of the last three thousand new admissions, comprising about two thousand fresh cases of insanity, less than ten have as yet turned out of this character. But, of course, I do not include the cases with merely long remissions, or the cases with relapses for the first year or two, or the demented cases with occasional spurts of excitement, or the women with a few irritable days at menstru- ation, though many of these are of the same essential nature as the most typical cases of folie circulairc, following the same laws of physiological periodicity in an irregular way. I have had under my care altogether about forty cases of typical folie circulaire. Of these about one-half followed a more or less regular monthly periodicity. About one-third obeyed the law of seasonal period- icity, all in an irregular way ; and the remaining sixth I could bring under no known law on account of their irregularity. I have one extra- ordinary case now, a lady, who was for a year deeply depressed, then for several years quite well, then for seven years more deeply depressed, then for three months passed for sane, but was really mildly exalted, then was depressed for a year, and has now been exalted, with all the typical symptoms of typical folie circulaire, for two years. COMMENCEMENT OF THE ALTERNATING TENDENCY. Though there are a few cases that begin with attacks of melancholia, yet in my experi- ence g at least ninety per cent, begin with attacks of maniacal exaltation. The ages of the patients on the first breaking out of the disease were all the way from fifteen to seven ty -four ; but every one, except the one D. C. (p. 177), began within the actively sexual and procreative period of life. I find no record of a w r oman's case beginning after the climacteric period. TERMINATION OF TYPICAL FOLIE CIRCULAIRE. As this cannot be determined till after the patients have died, it is impossible for me to give accurate figures; but, of forty cases, five ceased to be subject to alterna- tion in old age after sixty, one of these was above eighty, two being women. The men were all left in a condition of mind and brain that might be legally reckoned sanity, though in all cases there was some mental enfeeblement or a tendency to be easily upset, with lethargy, want of spontaneity, and of volitional power. One case terminated in complete dementia. Two ran on into chronic mania. Two died of exhaustion during a maniacal period. Three things are sure about the prognosis 1. Its utter uncertainty. 2. Recovery cannot be looked for at the climacteric period in many cases. 3. About twenty per cent, may be expected to settle down into a sort of quiet, comfortable, slightly enfee- bled condition in the senile period of life. 4. In my experience very few, indeed, become completely demented. 5. The tendency to death is very slight. GENERAL CONCLUSIONS. Looking at all those facts and considerations, therefore, I come to these conclusions. That periodicity or a tendency to alternations of elevation and depression is an almost universal charac- teristic of mental diseases ; that it is much more marked where they are very hereditary than in any other cases; that it is more common in youth, puberty, and adolescence than at other periods ; that it is in its essential nature merely the exaggerated or perverted physiological diurnal, menstrual, sexual, or seasonal periodicities of the healthy brain : STATES OF MENTAL ALTERNATION. 185 that the eases that have been called folie circulaire, katatonia, etc.. are merely typical or exaggerated or more continuous examples of that universal tendency to which I have referred. Another remarkable fact about the typical form of alternating insanity is. that by far the greater number of persons who suffered from it were persons of education, and far more than a due proportion of them were persons of old families. I never met with a fine case in a person whose own brain and whose ancestors' brains had been uneducated. It seems to me that the tendency to alternation of mental condition, to energize at one time with morbid hurry and then with morbid slackness, is one of the forms of brain instability which specially results from too much u pureness of blood," or from the heredity of many generations of gentlefolks, all of whose brains had been more or less educated. Probably it is one of the modes by which nature brings that kind of stock to an end that has become bad by over-brain cultivation for many generations. Real work can sometimes be done during the sane periods. D. D. has done some literary work, in the intervals of his attacks, for the twenty- six years he has been ill. I have no doubt that it was the sexual and menstrual periodicity of mental diseases, seen in so many cases, that formerly originated the absurd idea that they depended on the moon's changes, and gave them the name of k ' lunacy." TREATMENT. The great point in treatment is to prevent the brain getting into the vicious circle of continuous alternation by endeavoring really to complete the cure in all cases of mania especially in all cases of adolescent mania and by prolonged quiet and brain-rest after attacks in persons who have shown a tendency towards recurrence and relapse. In them particularly the whole organism should be kept up to physiological perfection. I believe that a non-stimulating farinaceous vegetable diet and no alcohol is the best for them, with an outdoor life and plenty of muscular exercise. A regular mode of life, too, without excitement, is best. One thing which I have heard recommended, and which is very liable to be resorted to in the beginning of the exalted stage when the patient is very erotic, is marriage, but I have never seen any good come of it either by cure or prophylaxis. I once, with Dr. Heron Watson, had to stop the banns in the case of a lady who had been seduced in the begin- ning of the exalted erotic stage of this disease, and was going to be married for her money by a scoundrel who had taken advantage of her mental condition. I mentioned in the case of D. A. that he usually pro- posed to many ladies at the beginning of his exalted attacks. There is only one class of medicines that I know which have any power of stop- ping or cutting short attacks, and of sometimes averting them for a long time, and these are the bromides, especially combined at the more acute stages with Indian hemp. The following three cases illustrate this action : D. F., set. 23. This young woman has had six attacks of mania in four years. She had been insane for four weeks previous to admission. All the attacks had begun during menstruation, and while maniacal she was always very erotic, especially at the beginning of the excitement. She was violent, incoherent, noisy, dirty in her habits, and sleepless before admission and for about three months afterwards. She then got 186 STATES OF MENTAL ALTERNATION. well, but in six months had another similar attack of mania, lasting for two months. She lost twenty-eight pounds in weight during this attack, and her temperature Avas always 1.5 above its normal rate during the excitement. She remained free from excitement for nine months, and then had another similar attack. After four months of sanity she one night suddenly got up, smashed the windows of her dormitory, saying that the devil was looking in, and became violently excited, her tempera- ture that day being 100.8, pulse 108 and strong. She was ordered drachm doses of the bromide of potassium every three hours, with a drachm of ammoniated tincture of valerian with each dose. She was put into a dark room at her own suggestion. On the following day her temperature was 99.6, and her pulse 108. She was still much excited, but not so much as on the day before. On the second day her tempera- ture was 99.3, and her pulse 130 and Aveak, the excitement being much allayed. The medicine Avas after this given only three times a day. She Avas left in bed for a fortnight in a dark room, as she said that if she got up she Avould get worse. At the end of that time she was still rambling, partially incoherent, and full of delusions, but nearly free from active excitement, and the medicine was discontinued. She remained slightly affected in mind for another fortnight. At the end of a month from the day the excitement began she was well, and was discharged from the asylum six months thereafter. I heard that she Avas still keep- ing Avell a year from the time of her attack of mania, which Avas thus cut short (as it seems to me) by bromide of potassium. I gave the valerian because she Avas beginning to menstruate at the time the mania began. It Avill be observed that the excitement in this attack only lasted about three days, and she had never been less than tAvo months excited at a time in her nine previous attacks. The aberration of mind was only of a month's duration. It had never been shorter than between three and four months previously, every symptom of an ordinary attack being clearly present at first ; and the interval of sanity has been even now longer than any such interval except that betAveen the fifth and sixth at- tacks. The excitement disappeared as the patient showed signs of coming under the influence of the bromide, and its constitutional symptoms Avere developed. D. (jr., set. 56, a woman Avho has been rather AA'eak-minded from birth, but got married and had children. She has been subject to attacks of excitement at intervals of a year or tAvo for tAventy years. On her ad- mission from another asylum she was found to be a little, thin woman, who went on talking quite incoherently, was restless and destructive to her dress, and violent at times. Sometimes she refused her food, and had to be fed Avith the stomach-pump. Though she got much food and stimulants, she became quite run down, thin, and exhausted in mind and body before the attack was over. The first attack lasted from March till the folloAving January ; she had a short attack in April. In the begin- ning of the next year she had another short attack, and in the December folloAving she had three epileptic fits (the first she ever had). They Avere the prelude to an attack of excitement Avhich lasted for six months. In the folloAving year she had another attack of excitement lasting for three months. In the beginning of this year she again became excited, and P LAT E IV. STATES OF MENTAL ALTERNATION. 187 was put on drachm doses of bromide and tincture of Indian hemp, three times a day at first, and afterwards morning and evening. The medicine BO completely moderated all the unpleasant symptoms of the excitement that she was kept in the infirmary Avard among the sick patients. She was not noisy, destructive, or dirty in her habits, as she had been before ; she did not lose flesh to nearly the same extent as before ; she took her food better than ever she had done before during excitement ; and the attack terminated in September, leaving her far stronger than she had ever been after so long an attack of excitement. This case illustrates the effect of the medicine on an old person very weak in body, and perhaps, therefore, more amenable to the effects of the drug. Such cases, when violently excited, are far worse to manage and cause far more anxiety than stronger patients in asylums, and therefore it is more important to have a mild and safe sedative. Another case is that of an old woman who has taken periodic attacks of mania for at least twenty years, and has been so much better during her last attack, under the use of drachm doses of the bromide and tinc- ture of cannabis morning and evening, that she has been kept in the in- firmary ward of the asylum during the nine months the attack has lasted, and has, during that time, slept in a dormitory with other patients, has taken her food, and is now passing into the quiet stage of her disorder. PATHOLOGY. As regards the pathological appearances found after death in cases of prolonged alternating insanity, I found in all of them more or less brain atrophy, especially affecting the convolutions, in all of them thickening of the membranes, in most of them thickening of the skull cap. One case, who had been twenty-five years ill, showed an amount of deposit of bone on the inner table of the skull I have never seen before (see Plate IV.). In most of them there was vascular disease, with, in one or two cases, local disintegration from embolisms and other results of blood-starvation. In short, I found the common pathological appearances in cases of chronic insanity, but with no special pathology whatever. That is what might be expected, for at the beginning the mental functions are so nearly restored between the attacks that we can expect no marked pathological changes. The whole tendency to periodi- city results, no doubt, from a mode of energizing, and not from struc- tural change that can be seen after death. No doubt such a deposit as that figured in Plate IV. is secondary and partly compensatory for the brain atrophy, but, like many of the changes of structure in the bones and membranes of the brain in chronic insanity, it is very instructive in the light it sheds on the pathogenesis of the disease. If the intensity of the morbid action was so great as to cause such structural changes even in the bones, how great must it have been in the convolutions, its primary seat! LECTURE V I . STATES OF FIXED AND LIMITED DELUSION (MONOMANIA, MOXO- PSFCHOSIS, DELUSIONAL INSANITY). THE study of this form of mental aberration should, like that of every other form, he begun from a physiological point of view. There are all sorts of false sense impressions and false intellectual beliefs which are due to mere physiological laws. When a light is rapidly intermittent and appears to the eye to be continuous, when the sensation of the toes and their movements are felt in an amputated stump, and when one is deceived by the quick movements of a juggler, we have for the time sense delusions. When through brain fatigue, brain poisoning, or dis- turbance of the circulation, objects are seen double ; or when the old im- pressions on the perceptive centres of the brain are projected and appear to be seen as real objects, the true nature of which have to be ascertained by the judging faculty, we have real hallucinations, but not insane hal- lucinations. The whole mental life of a child in its very early years. before its senses are trained or its judging power developed, is one series of delusions. The superstitions of the ignorant are delusions, but they result from lack of training and want of development of the judging power, not from a diseased perversion of it. When lately a great part of the Mohammedan population of Constantinople turned out one night, and with frantic gesticulations, great shouting, and firing of guns, tried to frighten away a beast which they believed to be devouring the moon when it was eclipsed, they labored under a delusion of ignorance. I have heard a perfectly sane but ignorant woman in Cumberland say that every time she had sat by the bedside of a dying person, she had heard the " Death Clock" in the wall; and whenever she heard that, she knew the patient was going to die, and had never been deceived. You meet with people who believe that certain things are going to happen on utterly absurd grounds, and so labor under delusions in a popular sense. Dreaming and nightmare give you the best idea of an insane delusion. and are the nearest physiological counterparts of it. A sufficient amount of fatigue and exhaustion from want of sleep will produce a condition in almost any brain that is closely allied to that of the nionomanaic. Such "delusions" have little relationship practically to "insane de- lusions," however much they may resemble them in certain respects, or however much they may be psychologically allied to them. The delu- sions that are really half-way house between those I have referred to and the true insane delusions are the false beliefs of imbeciles and the temporary delusions of persons whose emotions have been strongly roused by religious services or contemplation, as when they see visions or hear voices. The imbecile has deficient judging power from want of STATES OF FIXED AND LIMITED DELUSION. 189 brain development, and often has, in addition, morbid energizing of his convolutions. His delusions have often to be treated as insane delu- sions, as when he imagines he is married to a woman, and wants to act on his belief, or when he thinks his neighbor's property is his own, and proceeds to use it. To us, as practitioners of medicine, the " insane delusion" is the one that affects the conduct or life, provided it results from a morbid condition of brain, either through deficiency or disease. An educated man who behaved in Princes Street as the Turks behaved during the eclipse would certainly be regarded as laboring under an insane delusion, and would run much risk of being sent to an asylum. The education, age, class, and even race in some degree determine whether any given false belief is an insane delusion or not. This is not perhaps scientific psychology, but it is the practical way we have to look at the matter as physicians. The whole subject of false sense percep- tions, sane hallucinations, and unreasoning unfounded "instincts" about things, though most interesting both from the physiological and medico- psychological side, I must not dwell on here too long. An " insane delusion" may therefore be defined to be ."a belief in something that would be incredible to sane people of the same class, education, or race as the person who expresses it, this resulting from diseased working of the brain convolutions." There was once an old gentleman, D. L., a patient in Morningside Asylum, who in his man- ners and conduct was all that was gentlemanly; in his emotional nature was benevolent "to a high degree; and in his dress and deportment ex- hibited no peculiarity whatever, but who calmly asserted that he was many thousand years old ; that he had known Noah rather intimately, and found him a most sociable man, but "a little too fond of his toddy;" that he once went out snipe-shooting with King David, who was a crack shot ; and one day gave St. Paul a lift on his gig on the Peebles road. I once had a patient, D. M., at the Carlisle Asylum, who was acute intellectually and morally irreproachable, but who, ever after a hemi- plegic attack, believed that twice two were not four, but four and a quarter, and who spent his whole time not devoted to keeping the asylum accounts which he did accurately on the "old system" in deference to our prejudices to making elaborate calculations by his own mode of arithmetic as to the distances of the stars and a new system of loga- rithms, constructing new quadrants, etc. The manuscripts filled two large chests at his death, which he solemnly left by will to the Univer- sity of Oxford. In both these cases there was no trace of the morbid mental depression or the exaltation that I have described. The delu- sions, which were perfectly fixed and unchanging from year to year during the lifetime of the patients, really constituted the insanity, and were examples, therefore, of delusional insanity or monomania. There are very few, if any, examples of a pure monomania that is, of a person who has one single delusion, and that alone. The ordinary form of this type of mental disturbance is for the delusions of the patient to refer to one particular subject or set of subjects, or for him to be morbid in a particular direction of intellect or feeling, while he is sound in most directions. The chief directions such delusions take are a. of 190 STATES OF FIXED AND LIMITED DELUSION. unreal greatness, 5. unfounded suspicions, and c. unseen and impossible agencies. MONOMANIA OF GRANDEUR OR PRIDE. I have a pauper patient, D. N,, who believes himself to be the rightful king of England. He looks sane, and is perfectly quiet and self-possessed in manner. He is a well-developed man, far above the average of his class in general looks and in facial expression. He told us his story with perfect calmness and coherence, rather apologetically, and saying he knew we would probably not believe him if he said he was heir to the throne. Then when he came to tell about his betrothal at thirteen to Queen Victoria (I have had a score of patients who Avere to have been married to her Majesty), and Prince Albert's adroitly slipping in, he got on to ground purely imaginary and delusional. The whole story was a queer mixture of wholly imaginary premises and much sound, but also much unsound, conclusions from them. Insane people generally do not reason rightly from wrong premises, as Loche said, but some of them do; and the simply delusional and the melancholic cases are usually the classes who approich nearest to this description. It is most difficult, if you believe his case is incurable, to pick a flaw in the reasoning of a melancholic who says, "I am miserable and incurably ill, and shall get worse, and lose what reason I have got. I believe all such people are better out of the way. I have all my life believed this ; therefore, I mean to put an end to myself as soon as possible." One premise is correct, and the other was held by him to be so when he was quite sane, and is held by many sane people. But in the case of the monomanaic, one of his pre- mises is indubitably wrong in the estimation of all sane people, but you cannot convince him of this. If twice two and two had made four and a quarter, as D. M. said it did, then it was not absurd to have devoted every spare moment of his life to the demonstration that the world had fallen into a serious error, and to working out a new system of astronomy and logarithms on a correct basis. D. N., the king, is an excellent blacksmith, and we get him to work at his trade in our shop. Nowa- days we do not allow our monomaniacs or insane people generally to dress themselves or to look like what they believe themselves to be, as they did of old. The antipathy to individualism which affects society in every direction is strong in asylums for the insane. We now dis- courage those outward manifestations of insane delusions that used to give a lunatic asylum its most striking character. The monarchs crowned with straw, the duchesses in gaudy spangles, the field-marshals with gro- tesque military uniforms, that could be seen in any asylum of old, you will not now see when you go through our wards. If the man with the millions of money, who is the rightful heir to the throne, affixes the top of a soda-water bottle to the front of his cap as a faint symbol of his position, it is at once unfastened. If the princess, who is the greatest beauty in Europe, bedecks herself too conspicuously with bits of colored glass and in conspicuous ribbons, they are quietly removed at night. The insane man, line his sane brother, in most cases soon adapts himself to his circum- stances, and submits to rule and public opinion. The last of the great characters of the older period of this asylum, D. 0., lived on into the present regime, and was allowed to wear the insignia of his rank, but I STATES OF FIXED AND LIMITED DELUSION. 191 have allowed no successor to arise. He was the " King of Kings," and wore a most elaborate crown of many colors, each part of which had a symbolic meaning. He was so picturesque a character about the place, and was so striking a clinical illustration of monomania of grandeur, and withal so harmless and useful in the garden, that I never ordered him to be discrowned. He had certain visions from heaven which he reduced to concrete forms in drawings and polished stones, and his relations with Queen A^ictoria were most intimate. One " cloud of the Lord " which he once saw on the top of St. John's Church, had taken most vivid hold on his imagination, for he cut likenesses of it on the bark of almost every tree in the asylum grounds, where they will remain for perhaps hundreds of years. The tendency to symbolism and morbid outward decoration is much stronger in the Celtic races than in the Teutonic, and in the female than in the male sex. In the Highland asylums it is almost impossible to make the patients abandon their conceits in dress. Such changes have their drawbacks, for no Dean Ramsay of the future will be able to compile for us such delightful stories of our fools, and our writers and artists will have to look out for less striking environments for their madmen than fool's caps and gewgaws, or chains and filth. Hallucinations of the senses are very common in this whole class, and also delusions as to the identity of the persons around them. I have a gentleman patient who, whenever he goes into Edinburgh, meets the late Emperor of the French, or the late Prince Consort. So marked is this tendency in some cases that it might be called a special form of mono- mania, that namely of mistaken identity. It is well illustrated in this letter of D. 0. A. : " MY DEAR MAMMA, I have been long in answering your last kind letter, but the real reason is that I have been always so scarce of news to give you that I could never make up my mind to sit down and write; indeed, I cannot say that I have anything to say at present. I was out on Saturday seeing Signer Bosco's magical entertainment in the Masonic Hall. I think I will just tell you all my ideas about the people here, as I do not think that they are fancies of my own. Old Captain G., surgeon of Uncle T.'s dragoon regiment, is here; he calls himself Dr. S., but I don't mind that. " Sir J. H. is here too, calling himself J. S. ' With frisking airs Miss pussy tries the power of she's gooseberry eyes to win the heart of every swain.' He is attendant on a Mr. Y., whom I have no reason to doubt now is a brother of the operatic singer that the Duke of Cambridge shot in the theatre in Vienna. I am positive that I saw Sir A. in the Meadows without his case of false teeth. Emperor Yea of China is here too, calls himself Mr. B. ; he is kept by a son of Lord C. Peter D. is head gardener here ; he, his wife and family live at the lodge at the gate on the road out to Comiston. 8. D. is here on the ground flat ; 1 think, when I recollect right, you put that idea into my head out at P. He is attended by Malcolm, a son of Abraham Lincoln's. He writes squibs in the papers about the ' Solo ' royal family. He gets the papers printed over at the asylum press for my use, but I never read them. Maggie F.'s brother is also one of the attendants here. Bell, the brother of the Private Bell of the 6th D. G., is here acting as general scogey. He is the man that J. bought Wasp from. The matron of the East House here is a sister of my attendant's ; they are both children of Lord C., and their mother is the cook to the East House. Abraham Lincoln's wife is here, kept by Miss D. Wilkes Booth and Miss Reynolds, Gregory, Mag Wallace and old Armstrong son is head attendant of the male wing, East House. " Kind love to you all, and I remain, my dear edie, " Your most aifec. son, " D. A. O." "Am I in a trance again when I say that you really cooked and eat the meat which came off my head ?" 192 STATES OF FIXED AND LIMITED DELUSION. But to return to D. N., who may be taken as a typical case of mono- mania of grandeur, his mind is not only affected by the delusion that he is king, but it is affected by an unreal tendency to elevation in all direc- tions, and it is also now somewhat enfeebled, as is commonly the case after many years in such cases. He often writes me long rambling letters, proposing various impractical modes of managing the asylum, and he is the greatest fault-finder in it. Then affectively he is different from a sane man, showing small love for his wife or children, and he takes morbid dislikes to people without real cause. He once went down to Leith to see his family, and went to all the houses of a certain street which he imagined belonged to him, and gave the inhabitants due notice to quit at the next term. He is, of course, very inconsistent to work as a blacksmith, he being a king ; but the conduct of by far the majority of the insane is quite inconsistent with their beliefs ; and then if he did not work, he would get no tobacco or beer to lunch, arguments that even royalty can appreciate. Sometimes the kings and cases of monomania of grandeur will not occupy themselves in common occupations. I have a "prophet of the Lord," D. 0. B., a joiner, who by no means at our disposal can be got to work at his trade. He says that the Lord has sent him a new work, and he must follow it. He sees visions from God all the time, which he puts down on paper, green and blue angels, sapphire prophets, etc. He will go to no amusements, or to church. I have another man, D. 0. C., with almost precisely the same delusion viz., that he is a " man of God " who is a capital worker in the garden, and enjoys a dance or a concert immensely. The mental disease in D. N. was first seen thirty-four years ago in an attack of melancholia from which he recovered in four weeks, and the present attack began twenty- nine years ago, also with an attack of melancholia, which, as it passed away, left him in his present condition. There is a strong heredity to insanity in his family, his brother having been a melancholic and com- mitted suicide, and his eldest daughter, D. 0. D., has been a patient here since she was twenty-two, being now a case also of monomania of grandeur, and believing herself to be a princess ; and her insanity began with melan- cholia. She is like her father, but was begotten when he was sane, when therefore his disease was with him a mere potentiality. But this is often seen. That law of neurotic heredity through which in each successive generation the neurosis appears at an earlier age than in the preceding one was exemplified in this case, for the father was thirty-three when he first became insane, the brother, who committed suicide, thirty-two, while the daughter was only twenty-two. The tendency towards early dementia that is usually seen in such strongly hereditary cases if they do not re- cover, is shown here, for along with her delusional condition she is also much more mentally enfeebled than her father, not being able to employ herself, not taking interest in anything, and having no mental vigor or spontaneity. In addition to the cases I have mentioned, I am able to present to you some of the most remarkable personages that have ever lived. Here is Jesus Christ, and here are the Prophet Elias, the Emperor of the Uni- verse, the Universal Empress, Empress of Turkey, the only daughter of God Almighty, Queen Elizabeth, four kings of England, one king of STATES OF FIXED AND LIMITED DELUSION. 193 Scotland, the Duke of Kilmarnock, the inventor of perpetual motion, a man who has discovered the " new elixir of life " that can cure delusions, twelve persons to whom this establishment and all that it contains belongs, a lady who daily and nightly has delightful conversations with the Prince of Wales and the rest of the royal family, a man who is to renovate humanity, and cure all our existing ills by means of a scheme he has in his head. The gentleman who has discovered the "new elixir of life" wrote out an advertisement setting forth its infallible virtues that would have done credit to the most successful patent medicine proprietor. He used to make it up in the asylum, and wanted much to try it on the patients, but none of them believed in him or would take his nostrum. But he was allowed to go out for a walk into town occasionally, being a harmless man, and I found that he used to take a few of his bottles with him, and sometimes sold them at five shillings apiece this monomaniac to sane citizens of Edinburgh ! Those are all calm and harmless people, some of them bearing them- selves in their deportment and manner as become such distinguished personages, though a few do not exhibit any outward or muscular indica- tions of their greatness, all in some way inconsistent, and absolutely un- moved by the most conclusive argument or evidence that their ideas are wrong and unfounded. They all looked on me as the fool to be pitied or contemned, who could not see their greatness. They were all in good bodily health, and all looked as if they would live as long as any of us. In considering the origin of this form of mental aberration, we see that all this imaginary grandeur and power has a physiological foundation in the brain-working of every man. The wildest of these beliefs are not half as extravagant as the day-dreams, imaginations, fancies, castles built in air, and longings of nearly every man and woman. And in comparison to the imaginings or even the beliefs of a child, they are tame. Compared with the dreams of most men, they are very reasonable indeed. It is very easy to conceive how the brain of a man with a heredity to insanity, of unstable constitution, of a proud imaginative disposition, would, when it became disordered in working from any cause, readily play its owner the trick of making him believe his day-dreams and longings to be realities. Once impair the judging power that enables us to compare and estimate facts, and we should all be kings or very great men at once. Sometimes the monomania of grandeur is combined with that of sus- picion and persecution. MONOMANIA OF UNSEEN AGENCY. Another marked type of delu- sional insanity is that of unseen agency. Such patients believe that they are electrified, that they are mesmerized, that noxious gases are blown into their bedrooms, that people speak to them and call them bad names through walls by telephones and out of the ground, that spirits and devils haunt them, that persons come to them at night and break their bones or ravish them, that persons read their thoughts, or have power over them to act on their thoughts. Most of those delusions im- ply a sense of ill-being on the .part of their subjects, or pain or discom- fort, the origin of which the patients misinterpret. I had a woman who for long believed the devil was inside her. At the point where she said he was, I discovered a cancerous tumor, of which she died in a few 13 194 STATES OF FIXED AND LIMITED DELUSION. months. This was merely assigning an insane and impossible cause for a real pain which she felt. Such cases are common. One of the most typical examples of delusions of being affected by electricity and this and mesmerism are the two most common of all unseen agencies of which the insane complain -was that of a woman, D. 0. E., who, at sixty-four, became possessed with the delusion that people were electrifying her at night. This idea came on gradually, with a little depression at first, until it made her life an evident burden to her, unfitted her for all work, and she accused her neighbors of " working the electricity " on her when she was sent to the asylum. We found she had had heart disease, ac- companied evidently by angina. The pain of this she attributed to people electrifying her. This continued, and got worse, till her death from the heart disease. In her dying moments she accused us of causing all her pain by the electricity, and affirmed that this was killing her. I have a case now with "a big serpent inside," in which the delusion originates in angina. It is more common to have delusions, and not to be able to trace out such obvious causes as those two cases. All constitutional affec- tions, such as cancer, tuberculosis, rheumatism, alcoholism, and especially syphilis, which cause brain anaemia, and local disturbances and pains, may, in a person whose brain is predisposed to mental disturbance, cause delusions of unseen agency. Dr. Hugh G. Stewart long ago described certain syphilitic cases who imagined that noxious gases were blown into their rooms at night, or driven into their nostrils. To prevent this they stopped the keyholes of their doors at night, plugged their nostrils and ears, wrapped their heads up. I have met with many such patients. It is evident that there is a general sense of organic discomfort in such men, which is misinterpreted into those delusions. Frequently the chronic irritation of the drunkard's stomach is attributed by him to living ani- mals inside, or to poison. I once had a patient, D. P., who had been a great drunkard, and had had many attacks of acute alcoholism, who said he had mice inside him, gnawing and running about. He was gradually cured or recovered in about two years, under a teetotal regimen, bismuth, easily digested food, and fresh air. I give here the letter of a syphilitic case, D. Q. : " Forced dreaming, forced vomiting from the stomach, forced glut vomiting from the throat, cold shivering by the forced thinking, sweating done in the same way, pains in the stomach any way they think. I think it is time that this way of pun- ishing should be stopped, and let me know if there is anything going to be done for my benefit ; and I want to see about bad usage. I think it was time it was stopped. I would thank you to let me know the real truth. I am, &c." This man was an old soldier, and had on admission all the appearance of the syphilitic cachexia. He used to talk constantly about his delu- sions, and be rather dangerous, but now, after five years, he never men- tions them except he is spoken to about them, and in fact scarcely speaks ;at all. His bodily health is much improved, and he works in the garden every day. The following letter was written to me by a man, D. R., who was very dangerous indeed from his delusions, often threatening to kill me, and, he afterwards said, often seriously deliberating whether he would do so or not : STATES OF FIXED AND LIMITED DELUSION. 195 "1st April, 1868. " MK. CLOTJSTOX, I now take the opportunity of writing you these few lines to let you know that I am quite well in health, but you have punished me sore, and I do not know what it is for. A week or two after I came here you let me alone, and then you started and did wrong with me, and all your attendants had some stuft' to stifle me with. I think it is a disgraceful affair, and John very nearly choked me. Some, too, at the table, for I think you have them put on to do so, and in the bedroom there is Adam , for I have catched him, and told him about it. On the 18th of February you crushed my breast, and on the 20th you crushed my left side in. I thought you had done for me, and on the 21st February you crushed the right side in. And the curious conversations you have been making with me at nights. It's a shame and a disgrace. You ought not to try to kill me altogether. 1 have stood bad treatment that would have killed ten men, and you ought to put a stop to it, for I have done no wrong, &c." This man seemed in perfect bodily health, and I could not discover any peripheral causes for the painful sensations he probably had, and which he so misinterpreted. But in every case I advise you to examine carefully into the condition and working of the great organs and func- tions, and the history of the patient, to find out whether there has been syphilis or rheumatism, or other constitutional disorder. Such delusions of unseen agency are often associated with hallucinations of hearing. Patients fancy that people Avhisper through floors, and down chimneys. One patient I had was tormented by people speaking down the chimney, another was constantly annoyed by people talking to him through tele- phones, and a man who had been a heavy drinker, and had acute alco- holism several times, said he was constantly subjected to a process which he called "ric-me-tic." That persons read their thoughts and influence their thoughts are very current delusions. Patients almost always com- plain most of unseen agencies at night, just as they have hallucinations most at nights, when there are no conflicting real impressions on the senses. It is very common for women to have the delusion that they are made insensible, and ravished at nights. One can, of course, more readily understand the explanation of such delusions than of others. I am told it is very common, indeed, for criminals undergoing solitary confinement in penal servitude to have delusions that they are worked on by electric batteries. Their weak degenerate brains, natural suspicions, ignorance, and the occasional use of the electric battery to detect impos- ture among them, seem to account for this. I once had such a man sent from Broadmoor Criminal Asylum to the Carlisle Asylum at the expira- tion of his sentence, a strong bad-looking, dangerous fellow, whom we regarded as the worst man in the place. After a few months he escaped, and after being in hiding among his friends for a short time, began to work, and has remained an industrious, self-supporting member of society ever since, and that after having been for years regarded as a most dan- gerous criminal lunatic. No doubt, having first to secure his safety from recapture and then to earn his own living, and being away from those whom he would consider his natural enemies, his mind would be dis- tracted from his delusion, and it would cease to have its former power over him to influence his conduct. In some few cases delusions of unseen agency are pleasant to the pa- tient, or at all events are not complained of. Some of the sexual cases are of this character. Such was the case in the man D. S., who wrote 196 STATES OF FIXED AND LIMITED DELUSION. me this letter : " Record of Miracles, The Reverend came to see me, and his countenance changed to that of my deceased uncle . My length while in bed was increased to about seven feet, and then made normal. When in bed a very pretty colored landscape, including cottage and woman at her washing-tub, appeared on the wall. The picture could not have been produced by the aid of the camera. P. Smith, casting a wry look at me, jumped from the floor to a height of a foot, then passed through a framed picture without injury thereto, and through a solid fourteen-inch stone wall, then came through the water- closet door to meet me. 'While peering in at the laundry windows a number of the girls' clothes flew off them while at their washing-tubs, and after about half a minute's nakedness their clothes came back to them, and they were properly fastened without their aid. Near Myreside Cot- tage, James S., astride a thin wire fence, was seen speeding along for about one hundred yards, the wooden posts forming no impediment to his 'wiremanship,' &c." I have under my care at present a gentleman, D. T., who believes he is under the power of " an automaton," which controls him, makes him scream out, talk nonsense, break dishes, etc. He is a quiet and most courteous gentleman, who, after having done one of those things, will reply, if asked why he behaved so, in a peculiarly measured calm manner " The automaton made me do it. I did not wish to do anything of the sort." He will say sometimes, still more calmly, " Will you write to the commissioners to remove the automaton ?" " I beg to renew my request of the 14th of July." MONOMANIA OF SUSPICION. The third great class of delusional cases are those of suspicion and persecution. This kind of delusional condition is essentially the same as the last, only it is not so great a departure from soundness of mind, but for convenience sake we separate them. Patients who labor under this form of mental disease do not attribute their annoy- ances to unnatural, unseen, or impossible means, but to the malevolence of real persons who plot against them, have evil designs on them, poison their food, annoy them, persecute them, prove unfaithful to their marriage vows, etc. We all know that the natural development of suspicion is very various in different people. Many people are of a suspicious temperament from the beginning, others are made suspicious by real experiences in life or by ill health. We know that the weak are always suspicious through- out the whole of the animal kingdom. It is the same with human brains. An element of morbid suspicion exists at the beginning of nearly all cases of melancholia. Nothing is more common than for such persons to imagine that people are looking at them, watching them, and following them about. I look on this as mental evidence of an ill-nourished or anaemic brain. But in the class of persons of whom I am to speak it is a chronic manifestation of a disordered brain. As we shall see when I come to talk of phthisical insanity, morbid suspicion is the most constant sign of the brain malnutrition that goes with a combination of a heredity to tuberculosis and to insanity. A man, D. T. A., who is a patient of mine, is full of suspicions about everyone near him. He thinks that everyone about annoys him on purpose. If another patient coughs, it is to annoy him ; if one spits, it is to insult him ; if one sings, the words STATES OF FIXED AND LIMITED DELUSION. 197 refer to him. His career is instructive. He was a soldier, and lived hard, had an attack of acute mania, and when the exaltation and excite- ment passed off, he was left in his present condition, and has remained so for twenty-one years. For the first thirteen years he was regarded as a dangerous man, and it was feared to put any sort of tool or instrument into his hand, for he was the hero of many fights in fact, fought or wanted to fight some one every day. But as he was a tinsmith originally, and I found him one day in a better humor than usual, I sent him to the tinsmith shop of the asylum, not without fears that he might murder some one. He had just before written this letter : "I write to you to let you know that I am much abused here by villains. I will be clear of the band of villains they have upon me. Be so good as come before they kill me. I am not able to stand death here. They have poisoned me many a time. I will not stand the bloody abuse that they are giving me. A fellow they call Hamilton [a fellow-patient who talked to himself] is abusing me most awfully," etc. With much tobacco and a little beer, of which he was very found, and many promises that all the " villany " would be ended if he Avould work well and not fight, we set him to work. He took to it at once, worked as if his life depended on it, hammered away at tin and copper plates, making them into utensils, and evidently found much satisfaction in the outlet that unlimited hammering and much noise gave him for his muscular energy and irritated feelings. He clearly treated the tin plates as if they were the " villains " that had been annoying him. The great difficulty was to provide him work enough, he got through it so quickly. From that day to this, now eight years, he has been one of the most useful members of our community. If he has a fight, it is usually on Sunday. He still has the delusions of suspicion, but they are not all-powerful in his mind as they were, and his countenance is less expressive of fierce passion. He has got to believe now he has some friends, and that mollifies him. Patients in this condition of morbid suspicion attach delusional impor- tance to simple acts, e. g., a man who got some porter for his health wrote me the following letter : " Sir, I find by the report printed in the papers that you date your appointment as physician-superintendent here on the first day of Aug. 1873. Who then justified my porter test?" He im- agined that I was testing his mental state by the porter. I had a clergy- man once, D. T. B., under my care, who fancied that a conspiracy had been got up against him to put him out of every curacy he had held, and to prevent him getting a living, that the bishop had been concerned in this, and of course magistrates and authorities had refused him redress. Here is part of a letter of his : " My dear Dr. Clouston, I have often er than once heard of your welfare, which I hope will go on prosperously so long as you are the true and faithful servant of God, though no further, as I told you. My state of outrage and wrong you know well or better than I do, for all to me is a complete mystery beyond what I do really know and have been compelled to feel. In places of this kind there is so much ' pantomime,' so I pay no attention to such nonsense. I have received no redress or improvement whatever ! ! What part you have taken in the wrong I am suffering you know. There are and have been several nice vacancies, one of which will suit me, though any part of 198 STATES OF FIXED AND LIMITED DELUSION. England, so as to be far off the atmosphere of asylums, will suit me. I am in constant expectation of 'freedom,' 'compensation,' and a 'benefice' of my own. I have merit and purity enough for a bishop" and so on for many pages of complaint and morbid suspicion. By the way, you will notice that he underlines much of his letter. The late Sir Robert Christison once said to me that he could usually tell a man who labored under insane delusions by the way he unnecessarily underlined his letters, and there is much truth in the observation. The most painful of all the cases of delusions of suspicion are those where a husband becomes insanely jealous of his wife, and suspicious of her fidelity without reason. After the full development of such a case, it is easy to see that such suspicions are insane, by the exaggerated way they are put, and by the utter want of evidence ; but at the beginning they are most difficult and unpleasant. I have now a lady in the asylum, D. T. C., quiet in manner, ladylike, and almost rational, who showed her insanity first by going to her clergyman and making a confidential report to him that her husband had given her syphilis, and he was accordingly at once summoned for ecclesiastical censure by the kirk-session of his church. Being a sensitive, nervous man, this had an extraordinary effect on him. From being fond of his wife, he suddenly conceived a hatred of her, believing that it was a deliberate plot to ruin him. Though other symptoms of insanity developed themselves in her, he never to his dying day could be made to believe that the syphilis delusion was any symptom of insanity on her part, but looked on it as simply wickedness. In her case the nature of her delusion seemed to be determined by the fact that she had a chronic uterine tumor, the uneasy sensations connected with which seemed to have suggested it. You should always look for bodily causes of delusions. I was once sent for in great haste, as a geentleman, D. T. D., was said to be killing his wife. I found a most respectable man, of first-rate business capacity, who had made a large fortune, and was still doing business, and who was reputed by the world at large to be perfectly sane, making the most outrageous allegations about his wife, and saying she had been unfaithful to him. I soon found that those accusations were of necessity insane delusions. He had seen her wink to scavengers as she passed them. He had met her just parted , / from a laboring man, with whom she had had connection under a wall, etc. i I have now in the asylum two quiet, rational-loooking men, whose chief I delusion is that their wives, both women of undoubted good character, / have been unfaithful to them. Keep them off that and they are rational. On that subject they are utterly delusional and insane. They, like most such cases, are incurable. As an example of a perverted sensation or a local pain causing a delusion, I have now a gentleman, D. T. E., with disease of the rectum, who maintains that people come at night and commit sodomy. It is not uncommon to find women of middle-life with the combined delusions that certain men want to marry them, but that other people are preventing this. Clergymen are the most frequent objects of this most undesirable fancy. I have met with at least a dozen cases in all ranks of life of this kind. The subjects of it are usually not marriageable or attractive-looking persons. I shall show you a one-legged dressmaker STATES OF FIXED AND LIMITED DELUSION. 199 of forty, D. T. F., with certainly no personal charms, who went to her clergyman and asked him to "proclaim" her and Mr. in church. On inquiry, he found the gentleman to be proclaimed had never spoken to her. He sat opposite to her in church, arid she said he looked at her in such a significant way that she knew he wanted their banns proclaimed. D. T. F. said it was all owing to a scheming neighbor that she was not married to Mr. . A morbid feeling of fear is often associated with that of suspicion, especially in the cases that have arisen out of melancholia. I have a patient who is afraid if I take out my handkerchief, that it means something evil towards herself, who is constantly saying "Now, doctor, I know you are going to do something to me, what is it to be?" It is common for patients with rnonamania of suspicion to conceal their delusions, except to intimate friends or near relations, for a long time, even for years, and when asked about them to deny that they believe them. We had a gentleman in Morningside (D. T. G.) once, who was full of morbid suspicions, believing that some of the people about him were other persons altogether, and that he was at times in danger of his life from poison. Yet for many years he never told these things to any person but one fellow-patient. Unlike the majority of such cases, he was to most persons a pleasant man ; his social instincts were strong, he was fairly happy, going all about the country on fishing excursions, and enjoying a joke and good story immensely. Before his death, when his brain disease had advanced, he was not so reticent about his delusions. I have now two patients, D. T. H. and D. T. I., who on their first admis- sions I had to discharge, because they denied their delusions so strenu- ously. In fact, D. T. H. was twice discharged for that reason. Yet they both labored under most insane suspicions, that the people in their houses and the streets annoyed them, and wanted to kill them. When- ever D. T. H. got a glass of whiskey, these delusions at once came out. On one occasion the second medical certificate for his admission could not be got, and he was tried before the Sheriff for threatening language. I had to say that I believed him to be insane, but that I had no proofs of it from himself. That was deemed sufficient, and he was committed to the asylum. I have another patient who has been four times in an asylum, and while there, has never uttered one insane suspicion, though full of these about his wife, and really most dangerous to her. There are cases of monomania not to be classified under those three headings. I have, for instance, a man in the asylum, D. T. K., who for ten years has never spoken a word, but who I may say in all other respects behaves sanely, showing no symptoms of morbid pride or suspicion. He is about the best joiner we have. We know he has a delusion which prevents him speaking, but what it is we can't find out. If he wants instructions about his work, he writes, but nothing will induce him to write why he won't speak. There are certain patients, too, who simply express delusions as to the identity of those about them, without any suspicious, fearful, or persecuted feeling. There is, indeed, a great variety in the symptoms of those who labor under delusional insanity. 200 STATES OF FIXED AND LIMITED DELUSION. PROPORTION OF CASES OF MONOMANIA. At the close of the year 1881, there were eight hundred and twenty-two patients of all classes in the Royal Edinburgh Asylum, and of these eighty-seven were cases of delusional insanity, viz. : thirty-five of grandeur, fourteen of unseen agency, and thirty-eight of suspicion. Of the eighty-seven, forty-eight were men out of the four hundred and twenty-one male patients, so that the proportion in the two sexes did not differ much. There were more cases of monomania of pride and grandeur among the women than among the men, twenty to fifteen; while of suspicion there were twenty-five among the men to only thirteen among the women. I found one marked phenomenon in the natural history of delusional insanity. Out of one hundred and twenty patients of the higher classes socially, all Avith edu- cated brains, and many of them of old families, there were twenty-three cases of monomania, or about one-fifth of the whole, while among the five hundred and fifty-four pauper patients there were only forty-four cases of this variety of mental disease, or only one-twelfth of the whole. The one hundred and fifty-eight private patients of lower social class were intermediate, and had twenty cases of monomania, or less than one-seventh. It would seem, therefore, that delusional insanity is most apt to occur in brains of the highest education. DIAGNOSIS OF MONOMANIA. I had a woman sent into the asylum lately who told me she was the mother of God. We had no history of the case at all. There was no general exaltation, no excitement, and no depression apparent. Was not that a case of delusional insanity ? Not in a correct use of the term, for the woman gradually passed into an attack of simple mania, ceasing to express this particular delusion after a few days. Therefore, you must always take into account the fixedness of the delusion or the delusional state, and the time the patient has suffered from it. Many maniacal and melancholic patients begin by expressing a single delusion, or exhibiting a single delusional state as the commence- ment of their general disease. I have met with plenty of cases, too, where from the very subacuteness of the mania or the melancholia, the symptoms of general exaltation or depression were not very evident, and a delusion stood out as apparently the disease, and yet the patient soon recovered. And as patients are recovering from mania and melancholia, they often exhibit delusional conditions for a long time after the general exaltation or depression has passed off. I had a patient who had an attack of acute mania lasting for three months, and after that, though quiet, industrious, and rational on most subjects, he believed his food was poisoned for twelve months. He then gradually ceased to believe his food was being poisoned, but he believed that it had been poisoned before for twelve months longer. I classify such a case as one of acute mania, not of monomania of suspicion. By the way, a patient's belief in the reality of his former delusions is not at all uncommon. A man says "no one annoys me now, but I was subjected to persecution at home and when first I came into the asylum." I should not keep a man in ?n asylum, or count him a monomaniac, or even reckon him as legally insane, merely because he believed in the reality of his former delusion, if he had ceased to believe in their present existence, any more than I should count a man insane who could not get rid of the impression that STATES OF FIXED AND LIMITED DELUSION. 201 the events of a dream had really taken place. The two chief things to be kept in mind in the diagnosis of monomania are : 1. Not to call any disease by that name that has not existed unaltered for at least twelve months. 2. When there exists along with the delusional condition any general brain exaltation or excitement, or any general depression, not to call it by that name till those have passed off. ORIGIN OF MONOMANIA. It arises in at least four different ways in different cases. 1. It is a gradual evolution out of a natural disposition, a proud man becoming insanely and delusionally proud, a naturally suspicious man passing the sane borderland with his suspicions. From going over our cases I find about one-fourth of them arose in this way. It is the most common origin of the disease. There is usually a hereditary predisposition to insanity in those patients. The disposition may in fact be regarded as the nervous diathesis out of which the mental disease springs. 2. It remains as a permanent brain result and damage, after attacks of mania and melancholia, especially the former, from which the patients recover up to a certain point, but no further. This is the origin of about one-sixth of the cases. 3. It arises from alcoholic and syphilitic poisoning of the brain and body, from traumatic injuries of the brain, or sunstroke, or from gross lesions, such as einbolic sufferings. This seems to me to be its origin in about one-fifth of the cases. Such have usually the delusional insanity of suspicion or unseen agency. They are the most dangerous class of monomaniacs on the whole. 4. Most of the remainder, comprising over one-third of the cases, seemed to me to arise either out of perverted organic sensations caused by constitutional diseases characterized by lack of trophic power and brain anaemia, notably tuberculosis, or out of perverted sensations from local diseases misinter- preted by the brain, as in the woman with cancer of stomach. As a matter of fact, a very large proportion of the cases of monomania of suspicion die of phthisis pulmonalis. Any man with an anaemic, ill- nourished brain, is apt to be morbidly suspicious. LEGAL IMPORTANCE OF INSANE DELUSIONS. Delusions are often of small clinical import, but are always of the highest value as a test of in- sanity from the lawyer's point of view. Therefore I advise you to bring them in always, if they exist, in signing certificates of insanity, in medico- legal documents, and in giving evidence before courts of justice. But you must remember there are harmless and dangerous delusions ; and if a delusion is obviously harmless, and does not bulk largely in the patient's life or affect his conduct, the law scarcely recognizes it as unsoundness of mind at all. It is quite impossible to distinguish scientifically between some vain or proud men, who dress and behave in an absurd manner, but do nothing needing interference with their liberty, and the man who thinks himself the son of George the Fourth, claims property that does not belong to him, and is therefore shut up in an asylum. There are plenty of persons doing their work in the world well, and yet they labor under monomania of pride or suspicion in a mild form. The now famous case of Mr. Wyld, who held an important Government office, and did his work well all his life, and yet had labored under the delusion of grandeur, that he was a son of George the Fourth, and left all his money to the town of Brighton, because that monarch had been fond of that 202 STATES OF FIXED AND LIMITED DELUSION. place, is one in point. He was held to be sane in everything he did but his will-making. I am constantly consulted by their friends about the insane delusions of persons who do not show them to anybody but their / near relations, and continue to do their work and occupy responsible / positions. I now know in Scotland lawyers, doctors, clergymen, business / men, and workmen, who labor under undoubted delusional insanity, and yet do their work about as well as if they had been quite sane, though they are not such pleasant people as they would have been if sane, espe- cially to their relatives. TREATMENT OF DELUSIONAL INSANITY. At the beginning, when there is a chance of the delusions not being quite fixed, there are two indications for treatment. The first is change of scene, circumstances, company, and occupation, which can best be done by travelling about. The mind may be sometimes diverted from morbid tendencies in that way. And while this is being done, the second indication should be carried out, which is to correct and cure bodily disorders, to treat con- stitutional diseases like tuberculosis and syphilis and anaemia by suitable means, and to remove every bodily cause of convolutional disturbance, to withdraw objects of suspicion, and to bring up to the highest possible mark the nervous and bodily tone. By this means there is no doubt that some cases, especially those characterized by morbid suspicion, can be cured, even after they have existed for years. I have even seen a marked case of monomania of grandeur get better. A man who for more than a year fancied himself the Duke of Kilmarnock, got quite well, through im- provement in his bodily health, and working in the asylum garden. In a few cases with hallucinations of hearing, the continued current through the brain has seemed to do good. But for the confirmed monomaniacs of all sorts, who will insist on carrying out their ideas, an asylum is the only possible place of care. Dr. Charles H. Skae cured a case of mono- mania of suspicion caused through an injury to the head by trephining. PROGNOSIS. The prospect of recovery is certainly very bad in cases of delusional insanity that have lasted for over a year, but one is surprised sometimes by occasional recoveries after many years. There is a tendency to mental enfeeblement as time goes on. Many cases end in complete de- mentia after a few years, and in most the intensity of the conviction of the delusion, and the aggressiveness with which it is put forward, tend to diminish as time goes on. Most monomaniacs live long, all but the cases of morbid suspicion, who, as I said, mostly die of phthisis. PROPHYLAXIS. I think something can be done in those who are pre- disposed towards delusional insanity by their nervous diathesis and heredi- tary predisposition to the neuroses alone or combined with a heredity to consumption, towards counteracting the morbid disposition. While the reasoning power still holds its sway, it may be used in deliberate attempts to reason a man out of his morbid tendencies. I think I have seen a man in this way, and by not allowing himself to dwell on morbid thoughts and feelings, keep in check a morbid disposition. Good principles and good habits of life help greatly in the same direction. The occupation may be helpful, too, in counteracting it. I have often seen monomania of suspicion arise out of a suspicious, reserved temperament in young men, through the thoughtless and cruel small persecutions and annoyances of STATES OF FIXED AND LIMITED DELUSION. 203 fellow-clerks and fellow-workmen. Human nature is not tender or con- siderate towards such weaknesses. I have certainly seen a proud dis- position become a monomania of pride through the injudicious pamperings and foolish adulation of female relations, and the encouragement of such a person in occupations and schemes beyond his capacity or means. No doubt temperate habits in all things are very prophylactic for the kind of brains I am now describing. I think I have seen cheerful family life cure a commencing delusion of suspicion. Association with their fellow- men is good for all persons predisposed in this way, provided they can get suitable company to associate with. To be suitable, it needs often to be opposite and complimental. In all persons predisposed to delusional insanity, the social instincts are apt to be rudimentary, and need develop- ment. There is no class of the insane who, on the whole, show their morbid tendencies at an earlier period of life than the monomaniacs, and, therefore, some of them can be prevented, the brain being still plastic. LECTURE VII. STATES OF MENTAL ENFEEBLEMENT (DEMENTIA, AMENTIA, PSYCHOPARESIS, CONGENITAL IMBECILITY, IDIOCY}. WE use the term "mental enfeeblement" not in its wide and popular sense, meaning any mental weakness or disease whatever, but in a special and scientific sense. It may be defined as "a general weakening of the mental power, comprising usually a lack of reasoning capacity, a diminu- tion of feeling, a lessened volitional and inhibitory power, a failure of memory, and a want of attention, interest, and curiosity in a person who had those mental qualities and lost them, or has come to the age to have them and they have not been developed." There are two great physio- logical periods of mental enfeeblement, viz., in childhood and old age. Consider the condition of a child of two as to reasoning power. There are many words indicating a lack of mental power that ha.ve two mean- ings, a pleasant or an unpleasant one, according as they are used in refer- ence to a child whose mindlessness is physiological, or to a man in whom it would be morbid. What more charming than "prattle," " artlessness," "childishness," " innocence," as applied to a child ? But, said of a man, they mean "chatter," "silliness," "want of sense," or "unwisdom." If the brain development is arrested before birth or in childhood, we have congenital imbecility and idiocy Amentia. Dotage must be reckoned as natural at the end of life. It is not actually the same as senile de- mentia, but there is no scientific difference. Mental enfeeblement, both in judgment, feeling, memory, and volition, frequently occurs in and after bodily diseases, especially after fevers. It also always occurs in the pro- cess of starvation to death. It frequently is seen after the exhaustion of long journeys, great exertions, severe campaigns, and great mental tension, strains, or efforts, such as business crises, sieges, etc. It also occurs after sudden or great emotional shocks, such as loss of children. Now, in all these cases the actual psychological condition may be the very same as in patients laboring under mental diseases proper, or tech- nical insanity. Yet we do not practically reckon them in that category, except they are unusually severe or very lasting. Still, the student of brain function and medical psychology, as well as the practical physician, finds a study of all those conditions of mental enfeeblement most profit- able. The conditions of mental enfeeblement that are ordinarily reckoned among mental diseases may exist in every possible degree, from the merest dulling of the keen edge of certain mental faculties up to com- plete loss of intelligence, feeling, and memory. One man may be just so much altered that his friends say, " He is not the same man he once was," and another may not be able to comprehend or answer the simplest STATES OF MENTAL ENFEEBLEHENT. 205 questions or to recollect his own name. A clever man may be left in such a condition that in his dementia he is more intelligent than another stupid man. A man may, while he is not energizing mentally, seem as other men are, or as he once was ; but, when he comes to think, or act, or work, it is seen that he cannot do so as before. In most cases all the mental faculties are enfeebled together, either pretty equally or one suf- fering more and another less. In a few cases some mental faculties are left almost intact, while others are almost destroyed. I have a patient now whose brain was once a most energetic and subtle one and his mem- ory extraordinarily retentive, who talks quite rationally on all kinds of subjects, if they are suggested to him or if you "draw him out," and argues most correctly, but who never originates anything, is utterly help- less in action, and who cannot tell you the day of the week or what he had for breakfast. The originating power of mind, spontaneity of thought and feeling, active vigor of will that highest quality of all, are always diminished or lost in dementia. I know a man who when well always impressed those with whom he came in contact as being a leader of men, and who now, after an attack of mania, has lost the power of producing that impression. As one of his friends said to me "I was always afraid of Mr. , and never could be familiar with him. Now that's gone." Pathologically and psychologically, the mental state of such a man is the sa^e in kind, if not in degree, as the absolute dementia of asylums. Yet, of course, the degree makes a great difference from a legal and social point of view. A man's mind may be slightly weakened and yet he may enjoy his personal freedom, and another man who is more affected has to be deprived of this ; but there is no line of demar- cation, and no test to distinguish between technical sanity and technical insanity in dementia. It must be remembered that in all insanity there is an element often a strong one of mental enfeeblement pure and simple. Most cases of exaltation have enfeeblement of judging power as well as of feeling. Many cases of melancholia are enfeebled as well as depressed. A typical case of dementia is one affected as this young man E. A. is. As he came into the room his walk was hesitating and almost shuffling, and you see his bodily attitude is one of diminished muscular and nervous vigor. He stoops, his face is vacant-looking, he has no curiosity as to where he is coming, or as to what I am saying about him ; when I ask him his name he tells it, but cannot tell the day, or month, or year. In asking him questions, I have to adopt means by speaking loud and sharply, or by patting his arm, to rouse his attention to listen to me. His mental operations are slow as well as weak, for it takes his brain long apparently to take up impressions from the senses, and still longer to evolve the outward process of speech in response. When I ask him "where were you born ?" he says, after a minute, " Oh yes, I think so." When I ask him "who is that?" pointing to a student, "that's my uncle John." "What place is this you are living in?" "I don't know." "Did you ever ask any one what place it was?" "Yes." "Are you sure?" "No." " How long have you been here ?" "This morning." (He has been here six years.) He cannot reason, he has almost no affec- tions, caring for no one, showing no pleasure in seeing his relations. He 206 STATES OF MESTTAL ENFEEBLEMENT. has no wishes, hopes, fears, or memory. He does not resist anything, and has no choice as between any two things. He has no fineness of feeling, no "tastes." His habits would become dirty and degraded if not looked after. Looked at from the purely bodily point of view, he has no keen appetite at all even for food, for he has been several times for- gotten in the garden over meal-times, and hunger did not bring him to dinner. He has no proper sexual appetite, though he masturbates in an automatic way. His temperature is about a degree and a half below the normal, his circulation poor, his hands blue and cold in chilly weather, his muscles flabby, his common sensibility much diminished, for you see pricking with a pin does not rouse him much. His digestion and the action of the bowels are good and regular, and the sleep power of his brain is perfect, in fact he would sleep too long if allowed to. There is a good deal of flabby fat on his body. Sores are slow in healing, and when he catches cold he scarcely ever coughs, though there may be much bronchial irritation. The reflex action of the cord is diminished, though the tendon reflex is normal. Last of all, and most important, that power of action and power of coordination of those marvellously innervated strands of muscles in the face that give "expression" to the face, seem to be utterly dulled and diminished, and the eyes are expressionless. It is clear that all the higher qualities of his brain are gone, and that even the lower qualities are much enfeebled. He is now demented ; but he was once an intelligent, educated man, who had an attack of acute mania, and was left, after that had passed away, as you see him. There are five chief kinds of dementia : 1. Secondary (Ordinary or Sequential) Dementia, following mania and melancholia or other insanity. 2. Primary Enfeeblement (Congenital Imbecility, Idiocy, Amentia, Cretinism}, the result of deficient brain development, or of brain disease in early life. 3. Senile Dementia. 4. Organic Dementia, the result of gross organic brain disease. 5. Alcoholic Dementia, following the long-continued excessive use of alcohol. As the last three varieties will be described under the headings of the senile, paralytic, and alcoholic insanities, I shall not further refer to them here. As every variety of dementia is incurable, and as the medical profession outside of public institutions has little to do with its treatment or manage- ment, I shall devote little time to this variety of mental disease. SECONDARY DEMENTIA. This always follows and is in a way the result of more acute mental disease, such as mania and melancholia, and there- fore may be called sequential. It is the most characteristic, the most common, and the most important of all the kinds of mental enfeeblement, so that when you hear of a person laboring under dementia, it is usually this that is meant. It is dementia par excellence, therefore. It is the goal of all chronic insanities. When a condition of morbid mental exaltation, especially when this has been acute mania, has existed for a long time, we find that the over- action usually causes a tendency to mental weakness as the exaltation passes away, and that this is apt to be left as a permanent brain condi- STATES OF MENTAL EN FEEBLEMENT. 207 tion. This is dementia. The same tendency is seen, but to a less degree, as the result of a prolonged condition of mental depression. This is the termination we most of all dread in acute insanity. All mental diseases when long continued tend towards dementia. When the matter is looked at pathogenetically it might be thus stated. For the production of most 'cases of mental disease we need a morbid neurotic heredity, or a prolonged cause of irritation or exhaustion. Then comes an exciting cause of dis- turbance strong enough to convert this tendency, this potentiality, into an actual disease, and a severe outburst of abnormal action occurs in the brain convolutions. The symptoms of this are the maniacal exaltation, or the melancholic depression. The abnormal action means abnormal nutrition as well as abnormal energizing. This, like all long-continued abnormal nutrition, tends injuriously to affect the minute and delicate neurine structure, the capillaries, the lymphatics, and the packing tissue of the gray matter of the convolutions. It even affects, as we have seen, the structure of the surroundings of the brain, the pia mater, the large vessels, the arachnoid, the cerebro-spinal fluid, the dura mater, and the calvarium. When this storm of morbid action at last passes off or ex- hausts itself, the cells have become so damaged that they are no longer fit to become the vehicles of normal mentalization their nutrition, their storage of energy, their receptive and their productive power being im- paired. The mental result of this is enfeeblement or dementia. Some- what the same thing occurs in coarser forms in all the coarser tissues and organs, e. g., the permanent damage to locomotion that results from long- continued rheumatic inflammation of a joint, to digestion from prolonged over-stimulation of the stomach, to sight from the intense lights of the desert or the Alps, to hearing from the continuous clang of an iron ship- building yard. You will remember, however, that from the very begin- ning there was probably a tendency towards that weakening of the mental functions of the brain which we call dementia. The great difference in effect between partial loss of function in the brain convolutions, and in any other organ of the body, is that in the former case the man dies to all intents and purposes, socially his right to liberty is gone, and his place among his fellow-men is taken by another. The following is a typical case of secondary dementia. E. B., a hand- some, well-developed, intelligent, and well-educated young woman, whose mother was insane, her sister a woman that " no one could live with," and a brother a confirmed drunkard, had, at the age of twenty-four, a cross in a love affair. At first she was depressed in spirits for a few months, then she took to a morbid eccentric religionism, and in six months became acutely maniacal. She remained so for a year. At the end of that time her whole appearance and expression of face were so different from the attractive girl she had been that her friends scarcely recognized the same person. Her face, that "mirror of the soul," ex- pressed no doubt the fancies and the passions that were evolved in her morbid brain, but there was also a vacancy and a physiological degrada- tion very manifest. About that time she began to sleep better, then to eat better, then to talk and scream less, then to be able to sit still longer and control herself more. This process of gradual quiescence went on for six months, faith occasional spurts of exaltation, and short relapses 208 STATES OF MENTAL ENFEEBLEMENT . into active mania. By that time she was getting fat, sluggish, devoid of interest in anything, and with no emotion. She did not ask for those who had been dearest to her, or exhibit any pleasure when they came to see her. She often laughed and talked to herself. Her speech and con- duct were best described as very " silly." Her memory seemed gone. All that education had done for her brain seemed to have disappeared, or ' could only be brought out in disjointed, incoherent scraps. The nameless charms of dress and manner and behavior of a bright young lady had ab- solutely disappeared. She was slovenly and not over cleanly, showed few likes and dislikes, no will of her own. Her face was vacant, her eyes expressionless, her motions slow and wanting in purpose and vigor, and her nutrition flabby. But she slept well, she ate very well but with little choice of foods, her digestion was good, her bowels regular, and her menstruation, which had ceased during the whole of the maniacal period, became regular. She is in fact dead to mental life in any proper sense, and so has remained now for many years, and so will remain till she dies of some disease that will not necessarily be a brain disease at all. Her chances of life are probably below those of a sound person at her age, but she may live long. These are the cases that form the bulk of the old inmates of asylums, and about whom their friends say, they seem to outlive all their sane relations and friends, because they are free from the worries and cares of life, and live a regulated existence under medical rule. In certain things E. B. did improve after the first two years. Her brain was subjected to a reeducation of a simple kind, but its capacity for this was limited. It had no power of acquiring any sort of high attainment in anything. She was taught to dress herself more neatly, to do a little simple work, to observe certain hours for meals, etc. Curi- ously enough certain mechanical achievements in which she had been well educated, so that they had become the automatic property of the ideo-motor brain centres, came back to her easily, and were well done. Such were certain kinds of ladies' work, and sewing. It was found she could play some of her old tunes on the piano, but the music was me- chanical. All the life and soul were out of it. She could not be taught the simplest of new tunes, no new stitching, no new dance steps. Every now and again she had a slight return of the maniacal exaltation, begin- ning usually at a menstrual period, and at the very beginning of one of these she would look and act more like her sane self than at any other time. She is placed under the control of social inferiors, and she does not resist. She lives in the asylum, and she does not ask why. She has no money, and she does not seek it. She forms no attachment, and she associates with the most incongruous people without feeling it. This is the type of all the cases of secondary dementia in its causes and symptoms. But there are, of course, great variety in the details of the clinical pictures. Attacks of melancholia may be followed by de- mentia, but this is not nearly so common as in the case of mania, except in the senile cases. Nothing more conclusively shows that conditions of depression are essentially less profound departures from mental health than conditions of exaltation, than the lesser tendency to dementia after the former. When it does occur it is a less complete dementia than STATES OF MENTAL ENFEEBLEMENT. 209 occurs after mania, and is nearly always tinged with a melancholic cast. Out of one hundred cases of dementia taken at random, whose histories I know, only twenty followed melancholia. All sorts of partial dementia occur. I have many patients in the asylum who look like other people, who converse with you rationally when you talk with them, and have no delusion, but they have no initiative, no originating power, no active desires, no power of self-guidance, or resistive capacity. I sent such a man out of the asylum lately, and he just sat down at home, would not work, would scarcely get out of bed, cared nothing for cleanliness and the decencies of life, and only earned ten shillings the six months he was out. Some persons in this state do some work in the world outside under suitable, interested, and kindly guidance. Sometimes a man is left after a maniacal attack mentally twisted, or has a curious mixture of enfeeblement and obstinacy. I know a gentleman who once had an attack of mania, and who now shows a mild dementia chiefly in either defying or being unconscious of the conventionalities of life. He goes about the streets often in a dressing-gown and slippers, he pays no defer- ence whatever to ladies, he eats at irregular hours, is " never to be de- pended upon" in anything, and yet he manages his affairs and seems happy in a way. In some cases a man shows mild dementia by slight degradations in his habits and feelings. I know such a man who is simply not so sensitive as he once was, not so particular in small things, is content w r ith worse fitting clothes, and is not so neat and clean in his ways. I know another case where it shows itself by what his friends call excessive laziness. He will not walk or work, or do anything in fact, but sit in the house and smoke. I know many cases where it shows itself in deficient inhibitory power over the appetites, the patients taking to drinking and sexual immorality. In other cases they simply sink into a lower social stratum, and evidently are more happy there than in their own. Such cases are commonly reckoned as being examples of mere eccentricity, but they are scientifically cases of partial and limited enfeeblement of mind. There are certain things that are of the greatest importance in relation to secondary dementia. The first of these is undoubtedly the length of the attack of the acute primary insanity. The risk of dementia is in direct ratio to the length of the maniacal exaltation. This does not quite apply to melancholic depression, the existence of which for long periods is not so damaging to convolution function. Beyond a doubt there are some cases that become demented after only a few weeks of maniacal excitement, when, in fact, it is clear that the tendency to it was present from the beginning, and when it was an inevitable doom of their brains. These are the brains which seem to have innate energizing power in them to last only for so many years, and then they fail and die as to their higher mental functions. Of course, it may be asked How do we know that this is not the case in all those that become demented, without reference to the preceding mania at all ? May not the mania simply be one incident on the road to mindlessness, and not the cause of the latter at all ? It is right to ask such questions. On the whole, the facts of a great number of cases make one conclude that a maniacal 14 210 STATES OF MENTAL ENFEEBLEM ENT . attack does damage the brain convolutions, and that the longer it lasts the more likely is that damage to be permanent. 2. The character of the primary attack influences the tendency to dementia as well as its duration. The more acute the attack, the greater tendency there is to subsequent mental enfeeblement. The acutely delirious state is the most damaging of all, no doubt. But to this rule there are many exceptions. I have now a case quite demented where the primary maniacal attack was very mild only amounting to simple mania, and that lasting but for a month or so. Then enfeeblement showed itself, and slowly progressed, till in four years there was deep dementia. I have even seen a few cases where a mental enfeeblement began ab initio without mania, without melancholia, without gross organic disease or epilepsy or alcoholism. Such cases are very rare indeed, how- ever. We can usually get evidence of some symptoms of mania or melancholia if we have the means of ascertaining correctly the patient's state. The habit of masturbation may cause dementia as a primary mental disease in young people with a strong neurotic heredity, without preliminary mania. But the great difference in the onset of the secondary or ordinary dementia from that of the organic dementia is the existence of a preceding attack of mania or melancholia in the former and its absence in the latter. 3. The number of previous attacks is no doubt of the utmost impor- tance in the causation of dementia, except in the case of those typical examples of alternating insanity called folie circulairc, which I have described. The case of D. B. (p. 175), whose brain has had over two hundred attacks of acute maniacal excitement in the last thirty-six years, and yet is not wholly demented, is a most striking example of the recuperative power of the brain convolutions. Speaking generally, the tendency to dementia increases in each successive attack. The relapsing tendency of adolescent insanity is to my mind an illustration of the two inherent tendencies in such brains the one to mental recovery and life, the other to mental death. And we notice that the sooner the relapsing tendency stops, the more likely is the former result to occur. It often happens that after a first attack of insanity certain mental peculiarities are left, seen it may be only by the patient's near relations and intimate friends. He is not " quite the same man." Each succeeding attack that he has leaves him with more marked peculiarities or weaknesses, until the final irreparable break-down of dementia is reached. You will constantly be asked your opinion of a man who has once been insane, to hold appointments, to accept trusts, to contract marriage, etc. One must frequently give a guarded answer, and this, not only after examination yourself, but after most minute inquiry from disinterested friends who have seen most of him. I find it often more difficult to pronounce a man sane and mentally competent than to pronounce him insane. There is no doubt that a man may fully and perfectly recover from attacks of insanity. They may leave not a trace behind them in any shape or form. I could point to hundreds of men and women who have been insane, and who now do their work as well as ever they did. It is a grave injustice to regard all men who have been insane as tainted and unfit to hold appointments of trust, though this is unfortunately a common prejudice. STATES OF MENTAL ENFE EBLEM ENT . 211 There is a risk, no doubt, but it would be, indeed, a terrible thing if mental disease were regarded as necessarily implying an incurable mental deficiency or a relapse some day. 4. The fourth element that affects the occurrence of dementia, and that we have to take into account, is the heredity of the patient. The common opinion undoubtedly is, both among the profession and general public, that a strong family predisposition to insanity means a bad chance of recovery in any particular attack, in other words, a tendency to dementia. Now this is not true as a matter of fact. Strongly hereditary cases are the most curable of all, but they are most liable to recur ; though many of them are undoubtedly incurable from the beginning. A strong and direct heredity implies three things, (1) instability of brain, (2) liability to attacks at early ages, and (3) liability to a recurrence after cure. 5. The fifth element in our prognosis is the age of the patient. A man who has youth on his side has a much better chance of coming out of a brain storm of acute mania unharmed ; but to disturb this calculation come in those cases of mental diseases, occurring at early ages, and in brains whose whole stock of mental protoplasm is exhausted in a few years instead of being sufficient to last through the whole life of the body. As we shall see when I come to speak of senile insanity, we may have attacks of mania and melancholia in the advanced periods of life, when the brain is in the stage of decadence and the arteries are very diseased, recovered from altogether, or only leaving a mild senility. 6. There is a state of mental weakness that frequently follows sharp attacks of mania and melancholia, which closely resembles dementia, and yet is quite curable. It is in reality a mild form of stupor, and I shall treat it under that heading. It is analogous to the stage of temporary exhaustion and reaction that follows all acute diseases. It is the period of functional rest but trophic activity, during which, through the vis medicatrix natures, organs that have been diseased heal, tissues whose nutrition has been disturbed eliminate morbid elements and become normal, and functions that have been altered or suspended resume slowly their activity. This period is of the highest importance for treatment. Rest, nutritives, tonics, sometimes stimulants, and counter-irritants are then indicated. It is the time for the use of the stimulating nerve tonics and vase-motor stimulants, such as strychnine, quinine, phosphorus, the phosphates and hypophosphites, shower-baths, friction to skin, the inter- rupted and continued currents, Turkish baths, followed by brisk sham- pooing, and blisters to the back of the head. I have a man who had become dull, stupid, and lethargic after an attack of acute mania, and he "wakened up" visibly under such treatment. I had a young woman who had ceased to speak, rouse up and begin talking and working imme- diately after a blister had been applied to the back of her head. I had a man who roused up not only in mind but in muscular activity, and in vaso- motor force, his hands getting warm instead of blue, under the use ol Parrish's syrup of the phosphates. This was stopped in a fortnight and he at once fell back. It was renewed and he picked up, and again stopped and he fell back. It was given continuously for three months till he recovered completely. 212 STATES OF MENTAL ENFEEBLEMENT. PRIMARY ENFEEBLEMENT (IDIOCY, CONGENITAL IMBECILITY, AMEN- TIA). I do not propose to say much about the conditions of primary mental enfeeblement, but rather to glance at a few of the most typical varieties. Ireland's 1 definition is that " idiocy is a mental deficiency or extreme stupidity, depending upon malnutrition or disease of the nervous centres, occurring either before birth or before the evolution of the mental faculties in childhood." " Imbecility is generally used to denote a less decided degree of mental incapacity." In short, idiocy and imbecility are conditions of mental enfeeblement resulting from want of brain development before birth or in childhood. The mental faculties were never there, their organ being unfit to manifest them. In dementia, as we have seen, they were destroyed or enfeebled in a previously normal brain. It is necessary that medical men in practice should have a general knowledge in regard to this as to any other disease about which their opinion may be asked. It is well to bear in mind certain things in regard to idiocy. 1. That there are great varieties of the condition, both as to symptoms, causes, treatment, educability, and prognosis. 2. That the mental deficiency is always accompanied by bodily weakness of some sort, trophic, resistive, and motor, which can often be treated with good effect by the ordinary resources of our profession. 3. That by heredity and physiological connection it is apt to be associated with scrofula, tubercu- losis, drunkenness, insanity, and crime. 4. That the main instrument of treatment must be a general bodily and mental education of a special kind, adapted to the physiological educability and potentialities of the individual brain under treatment. CONGENITAL IMBECILITY. This may exist in every degree, from the smallest amount of mental weakness down to idiocy. Here is a case : E. C., now twenty-five, of a family in which both drunkenness and insanity had occurred. When a child he was well developed, and apparently like other children, till he was about three or four years of age, when it was noticed that he was not so bright, not so imitative, and not so observant as a child at that age should be. Speech was long in coming and difficult to learn. As he grew older he could learn almost nothing at school ; his school-fellows annoyed him, and he showed violent, ungovernable passion and violence. The faculty of inhibition is almost always weak in imbeciles, but they are not all passionate or ungov- ernable. At puberty he got much more difficult to manage at home, and all his weaknesses and peculiarities were thus more observable. Unfortu- nately he was not then sent to a special institution for the training of imbeciles. He could have been then taught much more than he now knows. In fact, I see no reason why he should not have learned some trade or mechanical work, and done it in a moderately efficient way. He got so irritable, and, when in a passion, so violent, that he had to be sent here about ten years ago. He has settled down into the life and routine of the place, is cleanly, tidy, and orderly in his habits, industrious in simple matters, such as bed-making, floor-washing, but is still very passionate and impulsive. He is happy and contented, and has no unfulfilled ambitions or longings to satisfy. Look at him. He is fairly 1 Idiocy and Imbecility, by W. W. Ireland, 31. D. STATES OF MENTAL EXFEEBLEM EXT. 213 developed. At ten yards' distance you would say he was an ordinary- looking young man. When you observe him closely you see there is a weakness in his expression of face, a lack of mind in his eye, and a sort of shuffle in his walk, while all his movements lack purpose and concise- ness. When he smiles he looks silly, and his speech is rather defective. You see at once there is no force in him of any sort, motor or mental. When further tested, his memory is seen to be defective, he cannot tell you how much four added to four and two off is. He can write, but like a schoolboy. You see that he is unfit to guide himself, to manage his affairs, to earn unaided his livelihood, or to resist any sort of temptation put in his way. He is in good bodily health, eats and sleeps well, enjoys simple pleasures like dancing, concerts, and juggler's entertainments, and may live long. E. C. is a good type of the must common form of congenital imbecile. There are others where one has much more difficulty in determining whether they shall enjoy civil rights and liberty, be allowed to marry, etc., being very near the minimum legally sane line. Such persons become the dupes of designing people, cannot resist temptation, or control natural desires, and often become the worst kind of dipsomaniacs. Some imbeciles show special talent in certain directions, some in music, some in drawing, some in imitation, some in a kind of constructiveness ; some, who are of a criminal class, are bad and depraved from the beginning are born imbecile criminals. As to treatment, the great things are, carefully to develop the body, to keep it always fat, not to give much animal food or stimulating diet, especially at puberty, to train in good habits bodily, mental, and moral to make their lives systematic and orderly, to avoid occasions of ill-temper, to punish justly and usually by deprivation of indulgences, to send to institutions for training and not to ordinary lunatic asylums till this is unavoidable. Congenital imbeciles may have attacks of maniacal excitement or melancholic depression in fact, are subject to them. They may become dangerous and even homicidal ; they may, after .an attack, have secondary stupor, or may become demented as compared with their primitive condi- tion. They are often terrible masturbators. IDIOCY. I find the most useful classification of idiocy is that of Dr. Ireland, as follows : 1. Genetous ; 2. Eclampsic ; 3. Epileptic ; 4. Paralytic ; 5. Inflammatory ; 6. Traumatic ; 7. Microcephalic ; 8. Hydro- cephalic ; 9. By deprivation of the senses ; and 10. Cretinism. Genetous idiocy is that variety which begins before birth. E. D. is a very unfavorable case. She is now twenty-four, and never showed any mental potentiality at all from the beginning. She showed no affection, no clinging to anyone in particular, not even like that of a dog to those who fed her and were kind to her. She has never had any understanding of anything, never could speak, always grunted in that animal-like way ?>u hear, never showed curiosity, imitativeness, or power of attention, ou see her body is squat and ugly, her temperature low, her palate acutely arched, and her teeth irregular and few in number. She has from childhood beaten her head with her hands, as you see her now doing, just as the gorillas beat their breasts in the African woods. Her face is utterly unhuman, hence such cases have been called theroid or beast-like. 214 STATES OF MENTAL ENFEEBLEMENT. The evolutionists would find many proofs of reversion to conditions common in the lower animals in her. When you place a tumbler of water on the floor before her, you see she kneels down and laps it with her tongue. She has not a rudimentary sense of decency or sexual feeling. Such a case is beyond the reach of teaching or training of any sort. Nothing can be done but to feed and clothe her and keep her clean. The next case of E. E., is a much more hopeful subject. He, too, is a genetous idiot, and is small, ill-developed, rather deformed, bandy- legged, cold, feeble in muscle and trophic power, but he in a way understands some things you say to him, is always smiling, is gentle, has been taught to be cleanly and almost tidy. He has no sexual feelings, cannot read or write or count, and will probably die of consumption. The genetous form the largest class of idiots, vary greatly in the mental capacity present, and many of them can be trained in training schools, and made more human and comfortable. The eclampsic idiots are those whose brains have been injured, and their development afterwards retarded by convulsions at dentition. They are an unfavorable class as regards training. The damage done to the brain and its envelopes is usually demonstrable after death. I produce before you a whole series of epileptic idiots. Their charac- teristics are : 1. That they vary in mental condition very much according to whether they are taking fits or not at the time. 2. That the effect of the constant recurrences of the epileptic seizures is such on the brain that it tends to lose the effects of training and to deteriorate. Take this example of E F., now sixteen, who has taken fits since he was a year old. At times he is gentle and teachable, and works in the garden, and enjoys life ; then he will have a few epileptic fits, and he will be stupid, dirty in his habits, and will forget all his training. After that he will be for a day or two irritable, violent, impulsive, and even danger- ous. He articulates in a childish way. He is getting worse, and will, no doubt, die some day in a fit or after a series of fits. I have seen the steady use of the bromide of potassium very useful in such cases, lessening the number of the fits and their severity, diminishing the irritability, and improving the nutrition. We have one boy here who is quite another being for the past four year under twenty grain doses three times a day. The paralytic form of idiocy is represented by this case of E. G., who was normal in body and mind till he was four years of age. He then had an apoplectic attack, and his left hand, arm, leg, and left side of his face and head are partially paralyzed, ill-developed, and the limbs shrunken, flaccid, and useless ever since. He takes sporadic epileptic attacks. He tries to articulate, but you cannot make out what he says ; he is restless, irritable, not very educable, weak, and cold. Such cases, looked at from the motor point of view by the general physicians, are called cases of Essential paralysis of infancy. The degree to which the paralysis and the mental affection are found in different cases varies from sanity to idiocy, from the slightest weakness to complete paralysis, shrivelling, and shrinking of the limbs. The pathology of those cases is very interesting. Often the convolutions in the affected hemisphere are found damaged and atrophied, the lower ganglia and centres undeveloped, and one-half of the spinal cord, as well as the motor nerves from it to STATES OF MENTAL ENFEEBLEMEN T. 215 the affected side, atrophied or not developed. I have never been able to understand why cerebral apoplexies occur in infancy. I am inclined to think that they are often not effusions of blood, but vaso-motor spasms from neurotic causes affecting certain of the cerebral vessels, and resulting in trophic damage to the parts of the brain deprived of blood. The inflammatory idiocy results from the inflammations and sloughings that affect the throat and ears in scarlet fever spreading inwards and damaging the brain. Certain portions of the organ are usually found to be hypertrophic in those cases. It is a very unfavorable variety. The traumatic variety is much like the inflammatory, or sometimes like the paralytic form, and results from falls and blows on the head. The microcephalic is a very interesting variety of idiocy. On the whole, the heads of idiots are smaller than those of sane persons, but there are many exceptions to this rule, and, as a matter of fact, the average sizes of the heads of idiots are as large as the minimum sizes of perfectly sane persons. Ireland says : " The size of the head gives no estimate of the comparative intelligence of the (idiotic) children." There is, however, a certain minimum size below which a head is incompatible with average intelligence. I believe a circumference of below eighteen inches means idiocy. Very typical microcephalies are rare, but, when seen, they make a strong impression. They look so impish and unearthly. They are usually active, alert, mischievous, imitative, intractable. I have no really good specimen, but E. H., with a head of eighteen inches in circumference, a small face, a small but perfectly well- formed body, an active, imitative way, and a restless manner, gives an idea of one. Her only deformity is a cleft and acutely arched palate. She just looks like a small dried-up woman, with small features and a most singular expression of face, and she smiles as if a baby was imitating the features of an old woman. Microcephalies should always be sent to training schools. They are often educable up to a certain point, and, if not educated, they are often little demons. Their muscular activity must find an outlet. The hydrocephalic variety of idiocy is very common, but I need hardly say to you that hydrocephalus with even enormous* enlargement and great deformity of the head is perfectly compatible with sanity. It usually has a dwarfing and, often, a deforming effect on the body. A small head is no proof that there has not been hydrocephalus. E. I. is a good example of a hydrocephalic idiot. She is now ten, and is slow in her movements, very gentle and patient, sometimes cries and moans, as if she had an organic sensation of discomfort in her head. Her head is globular, the fontanelles raised, the temples projected. She looks unhealthy, has scrofulous glands, and a feeble constitution. Her temper is good. She is educable, and worth educating. I am going to have her sent from this to an imbecile training institution. Drs. Batty Tuke and Campbell Clark described very fully the condition of the brain in hydrocephalic idiocy. The former found enormous hypertrophy of the neuroglia, and the latter found a floating lobe or portion of brain, unattached to any other nerve tissue, which could never, therefore, have exercised nerve functions, yet it had nerve cells and fibres in a primitive form. 216 STATES OF MENTAL ENFEEBLEMENT. Idiocy may occur by deprivation of the senses only. The famous case of Laura Bridgman, who was blind, deaf, and dumb, and with an indis- tinct sense of smell, but with common sensation, through which Dr. Howe educated her brain, developed intelligence and emotion, and raised her from a condition of absolute idiocy to one of great mental capacity, is and will always be the classical case of idiocy by deprivation. She differed essentially from most other forms and cases of idiocy in having a brain well developed and apparently normal in all respects, except that its inlets and outlets were obstructed. Ordinary deaf-mutism is closely allied to idiocy, and is one of the hereditary neuroses. To me it is a physiological sin that marriages between such persons should be legal. Cretinism is an endemic disease occurring in connection with goitre in some valleys of mountain chains, such as the Alps, Cordilleras, and Himalayas, and not found here, so I need say nothing about it. It is very interesting from an etiological and pathological point of view, and has quite a literature of its own on the Continent. LECTURE VIII. STATES OF MENTAL STUPOK (PSYCHOCOMA). You will not find stupor put among the ordinary symptomatological varieties of mental diseases, along with mania, melancholia, etc. This I think is a mistake. The only objections to its being so placed are two that it is not commonly a primary disease ; and that the word stupor does not imply to the lay or even to the medical mind any necessary mental disease at all, as they understand it. But these objections should not prevent us using the word to express in a correct scientific sense a morbid mental condition, which is different psychologically and clinically from all other morbid mental symptoms, which, while it lasts, demands different treatment from them in many cases, and has a different course and termination. Stupor used in this strict medico-psychological sense may be thus defined : "A morbid condition in which there are mental and nervous lethargy and torpor, in which impressions on the senses produce no outward present effect, in which the faculty of attention is or seems perfectly paralyzed, in which there is no sign of originating mental power, in which the higher reflex functions of the brain are paralyzed, and in which the voluntary motions are almost suspended for want of convolu- tion al stimulus, but where the patients usually retain the power of standing, walking, masticating, and swallowing." I look on mental stupor as essentially the expression of an exhausted, lowered, and devitalized brain. A typical case of this condition stands for hours where he is placed in the same attitude, when spoken to he takes no notice, he shows no active desires or affections, he does not speak or move, or show any interest in anything. His expression of face is vacuous, his vaso-motor power is usually much below normal so that his extremities look blue and are cold, he does not obey the calls of nature, or take any notice of them at all. Loud sounds make no impression, pleasant or terrible sights that would in others produce motion and emotion fail to do so. A woman once committed suicide by hanging herself in a dormitory at Morningside in the presence of another woman in a condition of stupor, who took no notice whatever of this frightful sight. Looking at the condition of stupor from the point of view of the phy- siology of the brain, we see that its power of receiving impressions from without is in abeyance, and its higher reflex functions are suspended. The mental and motor irritation of a full bladder or loaded rectum is not felt by the higher brain centres ; and when through the action of the lower centres, evacuations take place, there is either no consciousness on the part of the higher centres, or, if there is, it does not result in the volition that prepares suitably for them, or in the vexation that would be 218 STATES OF MENTAL STUPOR. felt in health, if they took place over the body. Even the ordinary skin and spinal reflexes are much diminished or abolished. The appetites for food and drink are paralyzed, or if felt are not followed by any exertion to satisfy them. A striking exception, and the only material exception to the passivity or suspension of brain function in stupor is regard to the reproductive instinct in a low morbid form. In the first place, most of the typical cases of stupor occur in the actively reproductive period of life. Most of them, in fact, are under thirty. Dr. Hack Tuke 1 found that twenty- seven was the average age in twenty cases. In my experience all the rery typical cases are nearer twenty than thirty. In by far the majority of the cases, the commencement of the disease had been connected with or accompanied by a sexual excitation in some form or other. Many of them had indulged in the habit of masturbation to a very morbid extent indeed, and had exhausted the brain energy thereby, had "stupefied" themselves, in fact, by this. Most of them indulged in this habit long after they had entered into a condition of mental stupor, doing it auto- matically rather than volitionally, and many of them have sexual delusions at the expiration of the attack. Many of these girls had 'been hysterical, and showed during their dis- ease marked hysterical symptoms. The aspect, expression of eyes, and behavior before the other sex, while consciousness existed, were markedly erotic, this being so in some of the cases, even after speech and all outward mental manifestations had ceased. Many of them have catalep- tic, trance, and hystero-epileptic symptoms, all these affections being most strongly, in my opinion, connected with the function of reproduction, its disorders, or its perversions. The direct connection of stupor in most cases with the reproductive and sexual functions has not been sufficiently considered hitherto. I look on those functions as the dominant vital activities from adolescence to thirty-five in many persons of the neurotic diathesis. If the inherent brain stability is hereditarily weak, with the inhibitory powers poorly developed, and if under those circumstances there is much intense sexual excitement or a constant sexual drain through masturbation or sexual intercourse, stupor, in some form or degree, is, in my opinion, the natural expression of the exhaustion of the higher nerve force that follows. We shall see examples to prove this presently. When I thus bring out strongly the connection of stupor with the reproductive function, it must be remembered that I am referring par- ticularly to that form which is attended by unconsciousness, though this may have a distinctly melancholic stage or tinge throughout (mental depression too being a symptom of brain exhaustion) ; and it must be kept in mind that there are cases of stupor of the melancholic type resulting from other causes, such as mental or nervous shocks, frights, losses, or bodily diseases, which have no reproductive or sexual complica- tion at all. The voluntary motor system is found, on examination, to be in three conditions in different cases or in different stages of the same case, viz., 1 International Medical Congress, 1881, Transactions, vol. iii. p. 638. STATES OF MENTAL STUPOR. 219 (1) quite passive, unresistive, and having no tendency to keep fixed posi- tions ; (2) cataleptic, with decided tendencies to keep fixed attitudes and positions, but with no resistance to external force used in changing the muscular positions; (3) resistive, showing a more or less strong resist- ance to external efforts to change the position. The first is commonly found in the anergic form of stupor, especially when it is caused by a previous acute attack by masturbation, general paralysis, or alcohol ; the second, also, in some of the anergic reproductive cases; and the last in the melancholic form alone. Looked at from the purely mental point of view, conditions of stupor are divisible into three varieties, viz., the unconscious the anergic where consciousness and memory are gone ; and the conscious the melancholic where they are both present, and where there is a delusion present, these facts being ascertained and tested afterwards by the patient's own account ; and the half-conscious or confused, where there is some consciousness, but by no means a keen or a correct subjective realization of events, and where the recollection of them afterwards is confused or delusional. Some cases pass through all these conditions in different stages. Conditions of mental stupor have excited much interest, and have an extensive literature, especially in France, to which of course I have no time to refer. Mr. Hayes Newington, when assistant physi- cian at Morningside in 1874, studied them carefully, and wrote a capital description 1 of them, with which I in the main agree; indeed, all must agree with him, for he sticks closely to clinical fact. He gave us the admirable word " anergic" to describe the passive, unconscious, non- depressed cases. This should take the place of the older term Acute Dementia, still commonly applied to such cases. It should certainly be discontinued, for it is confusing and incorrect. If you take a typical case of either the melancholic or the anergic, each undoubtedly cor- responds to his descriptions; but an extended clinical experience has shown me that the same case may begin by being in the condition of melancholic and conscious stupor, and may end by being in the anergic and unconscious. Then I find that by far the greater number of the cases that were anergic during the greater part of their course had a short melancholic stage to begin with. As for stupor being a primary affec- tion I call to mind very few cases where it was entirely so. It scarcely ever begins as stupor. There is a stage of mental depression or of mania, very short, it may be, but still present. The stupor may have been the disease for all practical and clinical purposes, but still the initiatory stage of another condition was there. The cases which we shall see, or to which I shall refer, will illustrate those various points of causation and symptoms. The best clinical division of stupor would be, I think, into the following kinds ; which, in the order of their frequency or importance, are : a. Melancholic stupor. b. Anergic stupor. c. Secondary stupor (transitory after acute mental disease). d. General paralytic stupor. e. Epileptic stupor. 1 Journal of Mental Science, October, 1874. 220 STATES OF MENTAL STUPOR. MELANCHOLIC STUPOR is by far the most frequent and the most important form. It is the melancholia attonita, or the melanclwlie avec stupeiir of the authors. As I have said, it is, either throughout its whole course, or at some part of it, the conscious and delusional form or the half-conscious looked at from the mental point of view, the resistive looked at from the volitional muscular aspect, and the non-paralytic looked at from the vaso-motor point of view. Some authors write as if there was always one overmastering delusion of a terrible kind, the patient fancying himself dead, or that he is too wicked to hold intercourse with his fellow-men, or that, if he speaks, he will be killed, which, as it were, fills the whole mental vision, and leaves no room for any other manifestation of mind, paralyzing speech and active volition of any kind. I do not think this a true view to take. There may or there may not be such a delusion, but by itself a delusion never causes stupor. There must be something more than this. There is always in addition a dis- tinct morbid condition of the brain affecting its reflex action, its trophic energy, its receptive power in all directions, and most especially its active ideo-motor functions. None of these things are the concomitants of merely delusional conditions. I look on the delusion as one symptom only, and not the cause of the melancholic stupor. Melancholic cases are sometimes suddenly impulsive at one period of the disease, and it is well to remember that during convalescence they may be suicidally impulsive. Gusts of motor energy seem suddenly to be evolved in the brain. I have seen epileptiform fits occur occasionally in such cases, but much more frequently a condition merely simulating epilepsy or apoplexy, the patient being conscious and having control over the muscular move- ments. Whenever you see a melancholic patient said to be "in a fit," always think of this condition. It is very common. In some instances this state occurs as the acme of an ordinary case of delusional or excited melancholia, being a short incident in the case. In other instances, though preceded by depression of mind, the stupor is the chief part of the disease. In some instances the stupor remains characteristically melancholic all through being conscious, resistive, and unaccompanied by vaso-motor paralysis. In other instances it passes into anergic stupor the patient being unconscious, unresistive, and with vaso-motor and trophic paresis. Some cases of melancholic stupor assume melan- cholic attitudes. Here is a young woman who lies flat on the ground, with her face on the floor, and she resists being placed on a chair. Here is a young man who is bent down till he almost crouches. Here is another who puts his fingers to his ears and keeps them there. The following are three cases of melancholic stupor, the first two (F. M. and F. N.) being patients of the ordinary type, and the third, F. 0., being a very extraordinary case in its severity, duration, and length of time he was artificially fed, and in its termination in recovery in these circum- stances : F. M., aet. 21, a well-educated, bright, clever, and industrious youth of sanguine temperament. No nervous heredity admitted. Habits tem- perate and correct. The cause of the attack was over-study when he was rapidly developing in body, and had not attained manhood. His brain was exhausted by the body function, growth, development, want of sleep, STATES OF MENTAL STUPOR. 221 and continuous mental effort. His first symptoms began eighteen months ago, and were mental depression, sleeplessness, and pain in the head. He got worse in mind and body, and soon became suicidal attempting to take away his life. He became suspicious too, his affection for his relations diminishing, and he was fickle. He then got so much better through rest and change that he resumed his work and studies. When he relapsed, a few weeks before admission, he became again very suicidal asking for poison, and wanting to drown himself. His motive for suicide was that people were going to kill him. On admission he was much depressed, though he could pick himself up and smile in a forced way. He was very suspicious, imagining that he had done some great crime, and that he was to be tried and would be hanged. He was thin, his muscles flabby, his pulse sixty and weak, bowels constipated. Tem- perature 97.2 in the morning, 96.4 at night. Weight, nine stone ten pounds. He was unsettled and restless at night as well as being sleepless. His appetite was poor. He was evidently all the time looking for the means of suicide, so he was carefully attended night and day. He got more confused and more obstinate, until in a fortnight after his admission he was in a state of complete stupor ; his countenance wore a heavy semi- vacuous, semi-depressed expression ; he would not answer questions or take notice of anything ; was utterly careless of his dress and person, letting his motions pass where he stood. The skin had a warm clammy feel, except at the extremities, which were blue and cold. He had a few lucid intervals of a few minutes each, when he would as it were wake up and ask where he was. The treatment from the beginning consisted of his being compelled to take an enormous quantity of milk and eggs in liquid custards, flavored with nutmeg, and with half a glass of sherry in each. He took usually in the day twelve eggs and six pints of milk, and began to gain in weight after the first fortnight. He had quinine and strychnine in moderate doses, and cod-liver oil emulsion, containing hypophosphite of lime and pepsine. He was walked in the open air a great deal. His skin was well rubbed with rough towels night and morning, and occasionally he had the continued current up to fifteen cells. He steadily gained in weight. After three months' treatment he began to speak, and wrote the following letter to his mother : " My mother, please let me go home. I don't know where I am. I feel very ill. Would you let me go home." In a few days he wrote to her to send him some money to pay for his maintenance here, saying that he thought about ,3000 would do, that he was a nuisance to those round him, and asking what great crime he had committed, and requesting that he might be punished adequately. In another month the confusion of mind was passing away ; in a month from that he was practically well in reasoning power, in feeling, memory, and in bodily health, and was over eleven stone in weight. He was bright, intelligent, lively, and a great favorite. He said he remembered in a confused way the events that occurred during his period of stupor, that he had the delusion all the time he had committed a crime, and was to be punished, and could not pay for the food given to him. When discharged, six months after admission, I never was more satisfied in any case that a complete recovery 222 STATES OF MENTAL STUl'OR. had been made. I always like to see a patient get fat on recovery from any form of insanity. This was a very typical case of melancholic stupor, showing well how the stupor was the acme of the brain condition, which showed itself first as melancholia, how there was a melancholic tinge through the stupor, and a distinct melancholic delusion. But I conceive it would be a mis- take to describe the stupor as being caused by a profound delusion. As a matter of fact, in this, as in all such cases, the intensity of realization of the delusion, and the capacity to feel keenly, were blunted by the con- dition of stupor. The stupor I look on as a brain condition distinct altogether from that of acutely felt depression in melancholia, in which delusions are vivid, and the misery profound. We find that delusions alone never cause stupor, whatever their character. They may cause prolonged taciturnity for years, but this is totally different from stupor. The condition of the mental portion of the convolutions in stupor is analogous to the stupidity of a nervous child when terrified or bullied. I do not see any but a superficial analogy between stupor of any kind and hypnotism. The following was a case of melancholic stupor of short duration, and with a complete recovery : F. N., set. 35. Temperament melancholic. Habits intemperate ; a prostitute. Heredity mother intemperate, and subject to periodic attacks of melancholia. Her illness began by melancholic depression and delusions, but she soon became excited, noisy, and tried to commit suicide. She had no great overmastering melancholic delusion to account for the stupor into which she soon passed after admission, which was complete with all the characters of melancholic stupor ; muscularly resistive, no cataleptic tendency, refusal of food, arid expression of face depressed. She would not walk or move, and had to be kept in bed. She remained in that state for about six weeks. It was evidently the acme of the attack of melancholia, and she shortly got better and made a good recovery in six months. She now says that the period of stupor was a blank to her, and she remembers nothing that took place then. The following was a case of prolonged melancholic delusional stupor, lasting three years, simulating "acute dementia," and requiring artificial feeding all that time, with final recovery. F. 0., set. 31. Admitted 26th January, 1876. Disposition retiring. Strumous diathesis. Habits unsocial, and almost too industrious arid sedentary. Excessive masturbation. Father intemperate ; mother died of consumption. Had one slight attack of mental disease (melancholia) three years ago, from which he quite recovered in a few months. First symptoms of mental disease were slight depression and foolish fancies. Along with these there were sleeplessness, pains in head, loss of nutrition, and great coldness of extremities. Sometimes he could not be kept warm by any means used. Was not dirty, destructive, or obscene, nor violent. Those symptoms showed themselves fifteen months ago. As he got worse, he opened a vein, and lost some blood, and on several other occasions he seemed to have tried to choke himself with a scarf. He was at times noisy and incoherent, and quite sleepless. He had changing delusions, e. g., that his brain was compressed by an evil spirit. STATES OF MENTAL STUPOK. 223 On admission he was depressed and hypochondriacal, fancying that he was dangerously ill, that he had been a great sinner and very licentious, that he suffered shame more than all mankind, and that his body had been tampered with when he had attempted suicide. Along with the depression there were much mental enfeeblement, facility, childishness, and impairment of memory, with rambling and incoherence. He had delusions about his sexual organs. He was ansemic, flabby, thin, and we thought that there was slight comparative dulness at apex of right lung, with rough breathing sounds. Temperature, 98.4. Height, five feet six and a half inches. Weight, eight stone thirteen pounds. He remained very much in this mildly melancholic condition for three months. He constantly wanted quack medicines, had a poor appetite, and used to twist and wriggle his body about in obedience to delusions. He then had an attack of deeper depression, with more confirmed delusions, intense insane obstinacy, impulsive violence, shouting at times and twist- ing his body about, as if there were beasts crawling on him. After this he refused food entirely in May, and was fed with the stomach-pump on May 7, 1876, resisting strongly. He took his food on the 17th, but again needed to be fed on the 18th, and for several weeks afterwards. Then for several months he took his food himself, his mental condition otherwise remaining much as before, and his delusions being very pro- nounced. But in May, 1877, he again began to refuse food, and from that time till April 30, 1880 a period of over two years and eleven months he took no food, and required to be fed twice a day with the stomach-pump. But this was not the most extraordinary part of his case. In the course of a month after his being fed, he had got into a condition of absolute stupor, lying motionless, insensible to pain, unable to stand, his urine and feces dribbling away, his circulation feeble, offering no resist- ance to anything done to him, and taking no notice apparently of any- thing. Nothing could rouse him, nothing could stir him, nothing could excite any mental or bodily reply or response, except that he shut his eyes tightly when the eyeballs were touched, and there was slight motion of the legs when the soles of his feet were tickled. But this last reflex power disappeared in October, 1878. Much difficulty Avas experienced in keeping him warm, but an old and most affectionate maiden aunt, who came to see him almost daily, contrived the most wonderful woollen foot coverings and body rugs. He was dressed in the morning, carried down to a sofa, and his penis inserted into an India-rubber bottle. There he lay all day, never moving, never resisting anything done to him. He seemed the most complete case of "acute dementia" or anergic stupor I ever saw, except for two things : these were, a certain expression in his face, which was never so absolutely blank as it is in that condition, and his not being able to stand or move at all, which seldom occurs. There was none of the resistance or muscular rigidity of melancholic stupor. As regards treatment, he was fed in the morning with a liquid mess, consisting of a pound of beef done to a liquid form in a large mortar with potatoes and vegetables similarly pounded down, the whole being made liquid enough to pass readily through a stomach-pump tube with beef-tea and a quarter of a pound of sugar. In the evening he had a custard with 224 STATES OF MENTAL STUPOR. three eggs and a quarter of a pound of sugar. His bowels kept regular. He had at various times quinine, strychnine, phosphorus, ergot, cod-liver oil, the hypophosphite of lime, iron, and the continued current up to twenty cells of a Hawksley's battery, used once a day for months together, through his brain and spinal cord. No good seemed to be done, yet he was a case about whom we never quite lost hope. His nutrition kept fair, and he did not lose weight. At last, in June, 1879, he was observed by his attendant to turn over on the sofa. Then reflex action on tickling of the soles was observed, and his countenance began to acquire more expression. The continued current was being used at this time, but I am very doubtful if it had any- thing to do with his improvement. In February, 1880, his glottis became more sensitive, so that the passage of the tube caused coughing, and he raised himself up after feeding once. One day he seized the tube and remained rigid and cataleptic for a few minutes. On April 30, 1880, he spoke for the first time, and at feeding time said he was tired of custards, and wanted some tea, took a moderate tea and supper, and a good break- fast. He had never lost weight during all the time of his artificial feed- ing. He took no food on May 1st, but on May 2d asked Dr. Clark, who was about to feed him, if it was the custom to keep sane men in the asylum, and on being told that it was not much like a sane man to refuse food, he replied, "Then if I take my food will that prove my sanity?" "Yes." "Then give it me at once." He took it there and then, and never missed a meal afterwards. He was weak and his appetite was feeble, but he soon began to walk, then to go out, and he got stronger, and heavier by nearly a stone than he was on admission. When asked about his stupor, he always gave some sexual reason such as that it was "gonorrhoea" or "emissions" that had been the cause of it. He asserted that he had been conscious all the time, and made some statements which proved that there had been some consciousness, reasoning power, and memory. He described how a sphygmograph was used on his radial artery, he told the names of assistant physicians who had been in charge of him during his stupor, and he "asked pardon for my conduct." His memory was not quite clear however ; he could not tell much about what happened, nor the year he entered the asylum. His memory of events before his illness was good, and he showed much curiosity as to what had been going on in the religious world. He was hypochondriacal, notional, and somewhat weak-minded, and was discharged relieved on June 21, 1880. He has improved still further at home, his old maiden aunt thinking him as well as ever he was in his life, and considering him a most intelligent and exemplary youth. She takes almost the entire credit of his resurrection, a distinction which I am much inclined to award to her, for she kept him warm, she kept up the interest of every one in his case, and she never despaired of his recovery. This was essentially a case of melancholic stupor (melancholia attonita, pyschocoma, melancholic avec stupeur), with many of the features of "anergic stupor." In fact, after the symptoms attained their greatest intensity, when there was no apparent consciousness, no attention, no muscular resistance, no voluntary motion, and no spinal reflex function, when the body temperature was very low, the capillary circulation in the STATES OF MENTAL STUPOR. 225 extremities was very weak, the urine and feces passing involuntarily and at all times, I considered the case as one of anergic stupor (acute de- mentia) that had arisen at first out of a melancholic condition, and used to speak of it as such, a fact of which the patient reminded me after his recovery. I certainly did not think there was consciousness, or attention, or memory really present, as the patient's recollections afterwards proved them to have been to some extent. In old times the case would have been called one of trance, and there were many of the features of what is now described in the books by that name. I think it probable that most cases of trance, if examined by an alienist, would be placed under melancholic or anergic stupor. It will be noted how well the digestive and trophic functions of the body were performed when there was no voluntary muscular action whatever. The great length of time during which the symptoms lasted, and the final recovery, so far as the stupor was concerned, are very marked features of the case, if they are not unprecedented. The following was a striking case of stupor (melancholic) following a mental shock: F. T., set. 55, of a melancholic temperament, and steady and indus- trious habits, through which he had made and saved <6000. There was no known neurotic heredity. He was a shareholder in the City of Glasgow Bank, and the failure of that ill-fated concern, and the loss of all his money, seemed to "take the spirit out of him" completely. He became sleepless, nervous, and much depressed. He lost weight from fourteen stone to ten stone four pounds. He first spoke constantly about his being victimized and cheated, and then expressed delusions that he was in debt, and that he must go to the police office and give himself up. His delu- sions by and by referred to his body (no doubt his organic sensations, as he got thin, weak, dyspeptic, and costive, were those of discomfort), saying that his inside was burnt up. On his admission to the asylum, six months after the beginning of his disease, he was with difficulty got to speak, to answer questions, or to take food; and he slept badly. He would appear as if he was to speak or answer a question, but the volitional power to articulate seemed to fail him, and he would say nothing. His next delusion was natural enough, the wish being father to the thought. He fancied he was dead, and he would say "I am dead; put me in my grave." Then for two months his stupor was complete, with no outward expression of mentalization at all. But the expression of face was; melancholic as well as stupid, and there was muscular resistance. He lay in bed. All this time he was getting weaker. No tonics excited his appetite, no stimulant and he got brandy in large quantities roused him, and his food did not nourish him. The news of his favorite daughter's death did not affect him. I have no doubt he had the delu- sion he was dead. He got thinner and weaker, and gangrene of his heel appeared, then hypostatic pneumonia, and lastly gangrene of the lungs, of which he died eight months after admission. In the last month of his life, and especially when his temperature rose to 102.5 from the lung disease, he would answer questions at times, and once or twice spoke sensibly, asking what sort of a night he had had, but generally he wanted to be put in his grave and "buried." 15 226 STATES OF MENTAL STUPOR. At the post-mortem examination we found considerable atrophy of the convolutions, and congestion of the brain substance. No dramatist ever drew a more vivid picture of adversity overwhelm- ing a man, striking him dumb, crushing the whole vitality of mind and body out of him, and soon killing him outright. This case brings out strikingly the lowered and devitalized condition of the brain, which I look on as, after all, the proximate cause of mental stupor. ANERGIC STUPOR (AcuTE DEMENTIA). This may be a primary dis- ease commencing without any melancholic or maniacal stage, though I have never met with a case in which I could not discover at least a trace of these conditions at the beginning of the attack. Its symptoms are complete unconsciousness, and of course no after memory of events that occurred during its persistence ; no delusions ; no muscular resistance ; but in some cases a static or cataleptic muscular condition ; a loss of facial expression ; a marked vaso-motor paresis, so that the extremities are blue and cold ; a lowering of the trophic energy, so that sores are apt to form and even gangrene may occur; the reflex functions of the cord are markedly diminished, and the higher reflex functions of the brain almost in abeyance. The following case, F. P., was one of anergic stupor, occurring in a girl of eighteen, who had had two slight attacks of melancholia on pre- vious occasions. One grandfather had been melancholic with delusions, but not in an asylum ; father had several epileptic attacks, and had been very "excitable" after each; sister became "dazed" after, and in con- sequence of, mother's death and died of phthisis in four months ; and a brother was eccentric and foolish. Masturbation suspected. The attack began by a short maniacal stage, with much incoherence, " laughing in a childish way." This passed into a condition of stupor in two months, during the continuance of which she never spoke, and stood in one posi- tion, or sat where she was placed. She swallowed liquid food when put into her mouth, but showed no desire for anything or interest in anything. Loud noises near her did not startle her. She did not obey the calls of nature. She was cold, her feet blue and swollen, her pulse weak and quick, and the reflex function of spinal cord abolished. There was no muscular resistance and no catalepsy. After about a month she seemed, under the use of stimulants, nerve tonics, and blisters to the occiput, to improve somewhat, but she soon fell back again, and remained ill for over a year. Menstruation, which had been absent for the first six months, returned, and she seemed to be none the better for it. As she began to improve she got a little obstinate and even violent, and her brain was for a time in the repeating state one sees sometimes in certain cases of mental disease. When asked a question she would repeat the words said, or part of them, like a parrot, as the reply. After she began to improve she rapidly got well, having been previously fattened with milk diet, and she has remained quite well now for seven years. This was a case with cataleptic symptoms. F. Q., aet. 27, admitted 2d April, 1881. Disposition bright and cheerful. Habits steady and industrious. First attack. No hereditary predisposition. Cause, anxiety in regard to an operation for removal of STATES OF MENTAL STUPOR. 227 mammary tumor which she had to undergo. Duration about five weeks. Became gradually depressed, lost appetite, fell off in flesh, slept badly. Ultimately became quite stupid, was unfit for her work, took no interest in her children, would stand in one position for an hour or two continu- ously, and was very restless at night. On admission she was in a state of stupor, paying no attention to questions addressed to her or to anything occurring near her, would not utter a word, stood in a listless and stupid attitude, obeyed no orders, refused food, did not attend to the calls of nature. She was in very poor condition and weak general health. She was unresistive, cold, and her extremities blue, and her face expressed vacancy, not melancholy. April 3d. Slept well for some hours, but was restless in the morning. Remains in a state of stupor, and will not speak a single word. There is a distinct degree of catalepsy. Has taken plenty of food. To have custards, plenty of extra milk, porter, and cod-liver oil emulsion, and friction to skin, with extra warm clothing. April 7th. Takes her food readily when fed with it. Still very stupid. Never utters a single word. Will not employ herself in any way. Wanders slowly and aimlessly about the gallery when set in mo- tion. When allowed to do so will sit or stand any length of time. April ~LQth. General health rather improved. Yesterday she spoke a few sentences to the attendants. April ~L5th. Expression of face more intelligent. Is obstinately taciturn. Sleeps well. April 30th. Bodily health improving. Mentally little change. May 31st. Has been worse since last note ; stupor more pronounced ; cannot be got to speak, or to work, or to attend to herself; wet and dirty in her habits. Nov. 1st. Stupor extreme. Sits constantly in one position, with head bowed down, and saliva running from her mouth. Eyelids are cedematous, pulse almost imperceptible, extremities cold. Ordered quiniae sulph. gr. iv., tinct. digitalis KI xv., three times daily. Nov. 27th. Has been confined to bed for some days lately, owing to the extreme general weakness. Mentally there is some improvement, as she brightens up slightly at times, but there is generally profound stupor. March, 1882. There is still pronounced stupor, but its character is considerably changed ; the mental faculties seem blunted or dead ; she is utterly careless and apathetic ; she is slovenly and dirty, requiring to be washed, dressed, and attended to in every respect ; she never volunteers a remark, and indeed never utters a single expression, except when being bathed or dressed, when she sometimes gives vent to expressions of dis- approbation and disgust. Her expression of face has also changed of late. Her general look is one of utter stupidity and degradation, the features being coarse and blurred, the saliva dribbling from the mouth ; but frequently, without apparent external cause, the face assumes various exaggerated expressions of disgust, amusement, and eroticism, while at times she has muffled outbursts of chuckling laughter. She takes plenty of food, and is in better health and condition. Muscularly she is cata- leptic to a marked degree. 228 STATES OF MENTAL STUPOR. In the next twelve months she improved in many respects, but she then died of diarrhoea. The following is a case of anergic stupor, beginning with slight melan- cholic symptoms, and caused by excessive drinking : F. R., set. 40, a person of a naturally bad and untruthful disposition, whose exact heredity is unknown. She is the daughter of a Hindustani mother, her father having been English. Her habits were always indo- lent, but of late they have been very drunken, fickle, and degraded. Her present attack began by melancholic fears that persons were going to kill her, restlessness, incoherence, and screaming at night. She still drank, and has become more and more confused and stupid. On admis- sion she was in a condition of stupor, with a slight melancholic tinge. This soon passed off, and her stupor became complete and anergic in character, with poor circulation, pulse weak, extremities cold ; urine and feces passed as she lay on a water bed. Nothing would rouse her to speak or take any notice of anything. For about a year this condition continued, and then she gradually came out of it in a partially demented condition, with uncleanly habits, erotic speech, masturbation, talking and laughing to herself, delusions of iden- tity, inability to fix her attention on anything, and a morbid contentment with her position in the asylum. Thus she has remained for four years now, and thus she will probably remain as long as she lives. The following is a complicated case of stupor, catalepsy with epilepti- form convulsions ; temporary partial recovery, dementia : F. S., set. 17, admitted to Royal Edinburgh Asylum, 2d May, 1874. Disposition quiet and dull ; habits steady ; family history not ascertained ; assigned cause a severe blow on the back of the head three years before admission, since which he has been duller and more stupid. The injury seems to have been chiefly spinal. After it he gradually lost complete control over the movements of his head ("it came forward"), then he ceased to be able to stretch his arms forwards and back, but he still could write. Was sick, and sometimes vomited. Could not walk far or run at all without being very tired. Had pain in his head. About three weeks ago showed mental symptoms, viz., religious anxiety, delusions that his food and medicine were poisoned, shouting, violence, and dirty habits. It appears that an epileptic fit immediately preceded those symp- toms. Took another fit sixteen days before admission, springing right up from his bed. Convulsions lasted three-quarters of an hour. During the fit the lip and tongue were bitten. He was then for five hours in "a trance." His head had been shaved and blistered. Had six or seven fits subsequent to this, and before admission. On admission he was in a state of stupor, with no mentalization ap- parent, insensible to pain, and spinal reflex action abolished. Pulse 130, weak ; temperature 97.8, was very weak ; urine and feces passed in bed. He remained in this stupor, but sometimes cried and moaned, and took many epileptiform fits for the first ten days. He then showed the true cataleptic symptoms, his body assuming any position it was placed in for any length of time. He took no notice of anything, and would not answer questions. One night the attendant got him up, put the chamber- pot in his hands under his penis, went away, and forgot all about it, and STATES OF MENTAL STUPOR. 229 he was found in the same position in the middle of the night by the night attendant. He remained cataleptic and unconscious for eight days, when he had a feverish attack with diarrhoea, temperature being 103. While this lasted, he could be roused to answer questions in monosyllables, and appeared to be more conscious and intelligent. After the fever subsided he again became completely cataleptic. There collected and ran out of his mouth a fetid greenish fluid somewhat purulent in character. Some- times he had to be fed with the stomach-pump. The food always had to be made liquid. During all the time, up till August 10th, he had mus- cular twitchings of the extremities, and occasionally a regular epileptic fit. Pulse then 60, weak and irregular; temperature 98.9. During September he began to move slowly by volition in a snail-like way, without speech or expression in his face. When up, and told sharply to get into bed, he would move slowly and manage to get there in half an hour or so. Bowels very costive. When much roused, on September 17th, he got up and walked along the corridor. There were no fits after the 18th of September. He steadily improved after this, still being slow and stupid, affectively religious, going to church, and saying very long prayers before going to bed. In October he was able to dress, undress, go out to do a little garden work, but stolid, slightly enfeebled in mind, reserved, wanting in curiosity and interest, and as if he had some latent morbid fancies. On November 8, 1875, he was discharged as "recovered," being co- herent and intelligent, but there was present some of the general listless mental state referred to. He did very well at home for a time, but a process of gradual mental enfeeblement seems to have come on, with irascibility and sometimes violence, so that, on 4th of June, 1878, he was readmitted to the asylum in a state of ordinary sequential dementia. He still remains there. He has never had any recurrence of the epileptiform fits. There are two additional facts which one may assume, though they do not appear in this record. The first is that there must have been a strong heredity to insanity. The second is that the lad practised mas- turbation to excess. He says he has no recollection of what occurred during his period of stupor. That I believe. I look on such a case as being partly caused by adolescence, complicated by masturbation and traumatism, all of which were concerned in the causation of the epileptic attacks and the condition of stupor. SECONDARY STUPOR. All acute forms of mental disease are liable to be followed, after the acute symptoms have passed off, by a condition of mental torpor and a kind of mental enfeeblement. But this differs es- sentially from the true secondary dementia. There is in it to a large extent the mental characters which I have described as being those of stupor, and above all it is curable. The patients are inattentive, con- fused, lethargic, and torpid. The brain reflexes are dulled. The ener- gizing of the convolutions is slow and confused. All the higher reason- ing and affective powers are in abeyance for the time being. It is a time of exceeding importance for treatment, which should be supporting, tonic, 230 STATES OF MENTAL STUPOR. nutritive, and not exciting ; though nerve stimulants and counter-irrita- tion to the head are often of service. GENERAL PARALYTIC AND EPILEPTIC STUPOR. The condition of stupor of the anergic kind is often an incident in those two diseases, most frequently following attacks of convulsions Or congestive attacks, but sometimes coming on of itself without any reference to such motor symp- toms. Wherever there has been prolonged stupor in general paralysis, we find much brain atrophy after death. CAUSATION. The causes of stupor are the following : 1. Sexual. The chief of these is the habit of masturbation. I have met with it also as a post-connubial condition, or from excessive sexual intercourse in both sexes in adolescents. In some cases it seemed as if the mental and emotional exaltation had acted as strongly as the physical exhaustion. F. P., and F. S. were examples. 2. Mental and moral shocks and over-work during adolescence. 3. The brain exhaustion caused by acute mental diseases, more especi- ally acute mania. 4. Stupor often occurs as an incident or stage in other mental diseases, notably, as we have seen, in general paralysis and epilepsy. 5. An alcoholic stupor may be caused by excessive drinking, and is thus one form of alcoholic insanity. Such a condition is usually transi- tory, but not always. 6. Stupor is frequently one of the stages of alternating insanity fol- lowing the exalted condition. It is more apt to occur in those where the exalted period is acutely maniacal. This stupor is usually the melan- cholic form. The older the patient the more apt is the stage of reaction after exaltation to be one of stupor. I have now under my care an old gentleman of eighty -four, who, when his periods of exaltation are unusually long, will afterwards become torpid, never speak or take any notice of anything, will not even stand, but must be kept in bed, will scarcely swallow, and this will sometimes continue for four or five weeks. When younger, he never had such attacks. He has labored under irregularly alternating insanity for thirty years. 7. Senility. In the extreme form of senile insanity, the mental facul- ties disappear so entirely as to constitute them cases of stupor. Some of these causes may, of course, coexist. The sexual and alco- holic are very apt to do so. PROGNOSIS IN STUPOR. In its typical form, in young persons of both sexes, the anergic form (acute dementia) is a very curable form of mental disease. The melancholic form is not so curable, but about fifty per cent, of the cases recover. TREATMENT OF STUPOR. All forms need much the same treatment, but in the anergic cases it needs to be supporting and stimulating, and in the melancholic more supporting at first, and stimulating afterwards. Quinine, iron, strychnine pushed to large doses, ergot, warmth, the con- tinued current, exercise, friction, alcoholic stimulants, rousing moral treatment, occupation, distraction of mind are the general indications. In the relation of the clinical histories of the cases described the treat- ment has been sufficiently spoken of. LECTURE IX. STATES OF DEFECTIVE INHIBITION (PSYCHO-KINESIA ; HYPER- KINESIA ; INHIBITORY INSANITY; IMPULSIVE INSANITY; INSANE IMPULSE; VOLITIONAL INSANITY; UNCONTROLLABLE IMPULSE; INSANITY WITHOUT DELUSIONS, EXALTATION, DEPRESSION, OR ENFEEBLEMENT; AFFECTIVE INSANITY). THE INSANE DIATHESIS. THE want of the power of self-control is so very common a thing amongst mankind, that to some extent, and in respect to some matters, it may be regarded as the normal condition of our species. A perfect capacity of self-control in all directions and at all times is rather the ideal state at which we aim than the real condition of any of us. The men who have attained this state of inhibitory perfection have been few and far between, and even in regard to them it may be said that they too would have lost their self-control if they had been exposed to sufficient temptation or irritation. But while a perfect mental inhibition may not be attainable, there is a certain amount of this power in all directions, and an absolute power in some directions that is expected of all sane persons. All sane men must control to some extent their animal desires, and they must control absolutely any desires they may have towards homicide. The law assumes, as the basis of all its enactments, that all men have the inherent power to do certain things and avoid other things that would be inconsistent with the well-being of society, or the safety or comfort of their fellow-men. If a man is born of criminal parents, and has been taught to prey on his fellows, and look on them as having no rights that he is bound to respect, if from no fault of his own his brain is weak, and no sense of right and wrong has been implanted in him at all, yet in spite of all this he is held as fully responsible by the law as the strongest, best taught, and most favorably circumstanced man in the country ; and this is at present unavoidable, however unscientific it is from the physiological and psychological aspect of brain and mind func- tion. Laws are, after all, largely the reflexes of the laws of nature. If a man has not been taught that an excessive use of alcohol damages or kills, and he drinks it to excess, he suffers just as much as the man who knows its bad effects, and deliberately poisons himself with it. But to this assumed power of mental control in all men the laAV makes certain exceptions. The first of these is in regard to children, and the second is in regard to persons whose mental power has been affected by disease or want of brain development. The subject of mental inhibitory power should first be studied by us medical men from the point of view of its gradual development in chil- dren. Take a child of six months, and there is absolutely no such brain 232 STATES OF DEFECTIVE INHIBITION. power existent as mental inhibition; no desire or tendency is stopped or controlled by a mental act. At a year old the rudiments of the great faculty of self-control are clearly apparent in most children. They will resist the desire to seize the gas flame, they will not upset the milk jug, they will obey orders to sit still when they want to run about, all through a higher mental inhibition. But the power of control is just as gradual a development as the motions of the hands. There is no day or year in a child's life after which killing its little brother is murder, and before which it was no crime at all. The law admits and provides in a rough way for this physiological fact as to self-control. We physicians see that this faculty is developed at different ages in different cases. We are bound to give credence to all physiological facts and laws, and it is as much a fact that different brains have different degrees of controlling power after their full development, as it is that they attain their power of control at different ages. As we watch children grow up, we see that some have the sense of right and wrong, the conscience, developed much sooner and much stronger than others, just as some have their eye-teeth much sooner than others ; and, looking at adults, we see that some never have much of this sense developed at all. This is notoriously the case in those whose ancestors for several generations have been criminals, insane, or drunkards. Then, again, in other persons the sense of right and wrong is painfully keen from early childhood, and the desire to follow the one and avoid the other earnestly striven after from the first. In some, therefore, conscience is anaesthetic, in others hyperaesthetic, just as sensation may be. Notoriously it is a bad thing to force any sense or mental faculty into too great activity till its brain substratum is sufficiently developed. I have known many children whose anxious parents had made them morally hyperaesthetic at early ages through, an ethical forcing- house treatment. I knew one little boy of four, who, by dint of con- stant effort on the part of his mother, was so sensitive as to right and wrong that he never ate an apple without first considering the ethics of the questions as to whether he should eat it or not; who would suffer acute misery, cry most bitterly, and lose some of his sleep at night if he had shouted too loud at play, or taken more than his share of the cake, he having been taught that these things were "wrong" and "displeasing to God." But the usual anaesthesia that follows too keen feeling succeeded to the precocious moral intensity in this child, for at ten he was the greatest imp I ever saw, and could not be made to see that smashing his mother's watch, or throwing a cat out of the window, or taking what was not his own, were wrong at all. We know that some of the children of many generations of thieves take to stealing as a young wild duck among tame ones takes to hiding in holes, and that the children of savage races can- not be taught at once our ethical feelings. It seems to take many gen- erations to redevelop an atrophied conscience. Professor Benedick, of Vienna, showed, at the International Medical Congress of 1881, in London, a number of brains of habitual criminals which he affirmed had their convolutions arranged in a certain simple form peculiar to the criminal classes, so that on seeing such a brain he could tell the ethical tendencies of the person to whom it belonged, just as you can tell a dog to be a bull-dog by his jaws. There is no doubt that an organic lawless- STATES OF DEFECTIVE INHIBITION. 233 ness is transmitted hereditarily. Among the many transmitted morbid peculiarities in the children of neurotic and insane parents this is often one. Either a too morbid intensity of desire, or a morbid weakness of control, renders such children prone to early morbid immoralities. In the delirium of fevers and the ravings of the acuter forms of in- sanity, no form of self-control is expected. The law, from the earliest times, entirely exempted persons suffering from such conditions from responsibility for acts done under their influence. A study of the dif- ferent varieties of insanity shows us that the power of self-control differs enormously in the various forms, and in different individuals laboring under the same form, while there is no line of demarcation between the state in which a man has "perfect self-control " (to use an expression that cannot be literally true in any case) and that in which he has none at all. Self-control, in short, like all physiological qualities and all mental faculties, exists in every possible degree of strength. Sufficient power of self-control should be the essence and legal test of sanity, if we had any means of estimating it accurately. The accurate clinical study of mind in relation to its ordinary physiological accompaniments, in health and disease, will, I believe, help us in time to make such an estimate in any particular case far more accurately than we are now able to do. The practising physician, from his daily acquaintance with the physio- logical facts of nature, instinctively makes allowances for lack of self- control in his patients when they are ill, apart from technical insanity. He knows that the thing called "irritability" merely means lack of full vital power, that the "impulses" of the hysterical girl are simply mor- bidly transformed modes of energy temporarily bursting the bounds of the patient's will, just as fits of weeping are often involuntary and uncon- trollable. But the lawyer, and the medical man, who, as a medico-legal witness or adviser, has to consider the social and legal aspect and effect of his opinions, are still chary of admitting mere loss of control or morbid impulse as an excuse for crime. They both like to have other evidence of disorder of the mental function, in the shape of insane delusion or incoherence of speech, before they are willing to put forward the plea of diseased want of self-control in mitigation of legal punishment. Another element than medical facts comes in then, viz., the practical effect of their opinions on society. In a community of perfectly law-abiding people a murder would naturally be attributed to disease, and no objection would be taken by any one to that view of it. But with the world as it exists, it is different. Before we can give any opinion as to the responsibility or irresponsi- bility of any case in a court of law, we should see as many cases as we can where want of controlling power or impulsive tendencies constitute the disease or the chief part of it. Such cases exist, though they are not, in a pure form, very numerous. As one stage in cases of insanity they are frequent. Half the suicidal melancholies at the beginning dread the moment when their self-control will be lost. Many of the maniacal cases show at an early stage only loss of self-control, before motor excitement or incoherence comes on. If one has seen many persons in this state about whom there could be no doubt as to their disease, and if one has systematically studied the loss of self-control or morbid impulse as a 234 STATES OF DEFECTIVE INHIBITION. mental symptom in the various forms it is found to assume, such experi- ence and study bring much confidence to us in giving private medical advice about this matter, or in giving evidence in the witness-box in regard to one of the most responsible and difficult questions about which a medical man has to come to a decision. Consider first the variety of simple motor impulses or acts that are physiologically uncontrollable, or partly so, such as coughing, vomit- ing, etc. Next, look at a more complicated act, that will be recognized by any competent physiologist to be automatic and beyond the control of any ordinary inhibitory power, e. g., irritate and tease a young child of one or two years sufficiently, and it will strike out at you ; suddenly strike at a man, and he will either perform an act of defence or offence, or both, quite automatically, and without power of controlling himself. Place a bright tempting toy before a child of a year and it will be instantly appropriated. Place cold water suddenly before a sane man dying of thirst, and he will take and drink it without power of doing otherwise. Exhaustion of nervous energy always lessens the inhibitory power. AVho is not conscious of this? "Irritability" is one manifestation of this. Many persons have so small a stock of reserve brain power that most valuable of all brain qualities that it is soon used up, and you see at once that they lose their power of self-control very soon. They are angels or demons, just as they are fresh or tired. That surplus store of energy or resistive force which provides in persons normally constituted that moderate excesses in all directions shall do no great harm, so long as they are not too often repeated, not being present in those people, over-work, over-drinking, or small debauches, leave them at the mercy of their morbid impulses without power of resistance. Some persons of more mental and nerve force have the fatal power of keeping themselves at work or at dissipation till this surplus reserve stock of resistiveness is altogether exhausted, and they then become unresistive against morbid impulses. Woe to the man who uses up his surplus stock of brain inhi- bition too near the bitter end, or too often ! In relation to the medico-psychological problems of mental inhibition and impulse, we have to take into account those obscure human ten- dencies towards killing, towards destructiveness, towards appropriation, towards unrule, some of which exist as inchoate physiological tendencies more or less strong in most human beings, and the gratifying of which gives pleasure. They are best seen in youth, and they often come out in a strong way in disease. Be they transmitted qualities of our far-off progenitors, or physiological weapons to help us in the struggle for exist- ence, or other and normal physiological energies transmuted, there they are, and we must accept them as facts of nature. The doctrine of nervous inhibition and of inhibitory centres has done very much to definitize our notions in regard to the mental working of the brain. There is, of course, no proof of mental inhibitory centres, but there is mental inhibition, and a function always implies an organ of some sort. When it was demonstrated that the excitation of certain nerves caused not motion, but stoppage of motion ; when it was proved that the nutrition of the tissues was largely influenced by the increased or diminished potency of the capillaries or arterioles, and that the latter STATES OF DEFECTIVE INHIBITION. 235 was dependent on two sets of nerves and two sets of centres, one to open and the other to shut those vessels, such physiological facts were at once correlated with the facts observed in conditions of mental excitation and depression, mental quickening and slowing, emotional supersensitiveness and torpor, and the conclusion was arrived at that in the higher depart- ment there must be a somewhat similar apparatus for regulating the exercise of the mental functions of the brain, and that disorders of these would probably make all the difference between sanity and insanity, between self-control and insane impulse. That there was a physiological analogy between the jactitation of the limbs of a man with chorea, who tries to control these motions, but is not able to do so, and the insane impulse to murder and violence which the patients are aware of, .deplore, and fruitlessly try to resist, but are totally unable to do so, seemed very evident. In the one case, a controlling centre or centres of motion are not doing their work, either from absolute loss of their own internal power of governance, or from an excess of energy generated in the lower motor centres of the choreic limbs; in the other, the controlling centres of mentalization and feeling are not doing their work for the same reasons. We know that there are controlling centres of even many of the lower reflex functions, and there can be no doubt that they exist also to control the great reflex functions of the cerebrum, which were so clearly ex- pounded by Lay cock. That doctrine has done much to make us under- stand better the mental functions of the brain and their derangements. Let us glance at an example. The maternal instinct of care and affection for offspring is a mental function of brain common to man with the lower animals, and ranks next to the love of life and the desire to reproduce the species in importance, while it surpasses these in conscious intensity for the time it is in operation. Its periods of activity are, of course, inti- mately connected with the activity of the reproductive organs. The objects of the instinct need not necessarily be the animal's own offspring. Cats will suckle and take tender care of young rabbits when their maternal instinct is in full activity after parturition and when the mammae are functionally active. There is a nervous influence sent up from these organs to some portion of the brain, rousing it into activity, and so developing the feeling for young, and the unceasing innumerable acts of care, defence, playing with, and protection, which for the time dominate the whole mental life and outward actions of the animal. Artificial irri- tation of the mammae without previous parturition will sometimes develop this instinct. In the case of the cat suckling the young rabbits, it entirely inhibited the opposite instinct to kill and eat them. In condi- tions of disease, the maternal instinct is completely perverted in its exercise, so that animals sometimes eat and destroy their young. Now, the same thing happens in the human species. In the insanity which occurs after childbirth one of the most common symptoms is either an entire inhibition of the maternal instinct, so that "a woman forgets her suckling child," or an entire perversion of it, so that she wants to destroy her own offspring. The physiological word inhibition can, therefore, be used synonymously V with the psychological and ethical expression self-control, or with the will / when exercised in certain directions. It is the characteristic of most 236 STATES OF DEFECTIVE INHIBITION. forms of mental disease for self-control to be lost, but this loss is usually part of a general mental affection with melancholic, maniacal, demented, or delusional symptoms as the chief manifestations of the disease. There are other cases, not so numerous, where the loss of the power of inhibi- tion is the chief and by far the most marked symptom. Those we are now to consider and study. I shall call this form "Inhibitory Insanity." Some of these cases have uncontrollable impulses to violence and destruc- tion, others to homicide, others to suicide prompted by no depressed feelings, others to acts of animal gratification (satyriasis, nymphomania, erotomania, bestiality), others to drinking too much alcohol (dipsomania), others towards setting things on fire (pyromania), others to stealing (kleptomania), and others towards immoralities of all sorts (moral in- sanity). The impulsive tendencies and morbid desires are innumerable in kind. Many of these varieties of insanity have been distinguished by distinct names. To dig up and eat dead bodies (necrophilism), to wander from home and throw off the restraints of society (planomania), to act like a wild beast (lycanthropia), etc. Action from impulse in all these directions may take place from a loss of controlling power in the higher regions of the brain, or from an over-development of energy in certain portions of the brain, which the normal power of inhibition cannot con- trol. The driver may be so weak that he cannot control well-broken horses, or the horses may be so hard-mouthed that no driver can pull them up. Both conditions may arise from purely cerebral disorder, or from cerebral excitation or paralysis caused by eccentric agency in the organs it may be reflex, in short. The former of these may be without consciousness at all, the ego, the will, the man being non-existent for the time. The most perfect examples of this are murders done during som- nambulism or epileptic unconsciousness, or acts done in the hypnotic state. There is no conscious desire to attain the object at all in such cases. In other cases there are consciousness and memory present, but no power of restraining action. The simplest example of this is where an imbecile or a dement, seeing something glittering, appropriates it to him- self, or when he commits indecent sexual acts. Through disease a pre- viously sane and vigorous-minded person may get into the same state. The motives that would lead other persons not to do such acts do not operate in such persons. I have known a man steal who said he had no intense longing for the article he appropriated at all, at least consciously, but his will was in abeyance, and he could not resist the ordinary desire of possession common to all human nature. I have known a married man indulge in masturbation in the same way. He knew it was wrong, and he had opportunity of sexual intercourse, but he could not resist this simple and unnatural mode of sexual excitation. Volition and resistive power were paralyzed. The second class of impulsive acts, where we seem to have normal volitional power, but the impulses so morbid and so strong that they can- not be resisted, is often seen by the physician in the early stages of mental disease before its symptoms have fully developed. Its existence may be called in question by a priori sociologists, may be ridiculed by journalists, and the dangers of admitting its existence may be painted in dark colors by lawyers, but that it exists as a fact in the history of human nature no STATES OF DEFECTIVE INHIBITION. 237 one can doubt who has actually seen the terror and agony of a mother conscious of an impulse to destroy her child, and striving against it with vehement resolution. A lady came to me lately to consult me, and this was part of her conversation : " Thoughts of putting myself away come suddenly into my mind when I am working and quite cheerful. Oh ! my God ! if I could get these thoughts out of my head, what would I not give? I could and do scream for relief sometimes. Oh. me! it's horrible ! It comes on me that some day I will take away my life or that of my children. I had this idea before I was married at times. My mother had it. It comes on me in one instant, and some day I will not be able to resist it. It seems now as if there was a galvanic battery up from your floor up to my brain that makes my head feel queer and tingling. Filthy words and bad thoughts shoot into my mind too in the same way." And she threw herself on her knees in an agony of dis- tress, beseeching God and me to deliver her from these homicidal and suicidal impulses. Yet a minute before she had been cheerful and laugh- ing, and a few minutes after she was the same. No doubt the theory of uncontrollable impulse is liable to abuse, and to be applied where it does not exist ; but one might as well assume that there is no real epilepsy because malingerers and hysterical girls simulate fits, or that there is no such condition as hypnotism because rogues, fools, and quacks dabble in deceit and call it mesmerism. The states of defective inhibition and impulse may be momentary in duration, or may be constant. They may be slight in form, or most in- tense. Their etiology is varied. As a general rule they are met with either in those hereditarily predisposed to the neuroses, or in those whose normal brain-functions have been impaired by over-indulgence in alcohol or nervous stimuli on the part of themselves or their parents. In some few cases a merely defective training of the brain in youth seems to end in morbid hyperkinesia. No doubt, if we could devise a perfect mode of teaching self-control to the young brain it would be an educational dis- covery the most valuable yet made by humanity. The great crises of life sometimes set up this condition puberty, adolescence, the climacteric period, senility. In many cases there have been congenital or early de- fects of brain development, causing volitional and moral imbecility, or what Morel called instinctive juvenile mania. Visceral derangements and reflex irritations are the causes in many cases. Who does not feel his volition or control sympathize with the state of his digestion. I knew a young woman who, during menstruation, which was with her difficult and painful, did all sorts of impulsive acts eat dirt, hurt herself, and pinch children while she was at other times amiable, and did none of these things. There is no doubt that the organic instinct of repro- duction becomes transmitted morbidly into instinctive impulses to kill, steal, etc. I shall confine my observations to the commoner and more typical varieties of morbid impulse, and they are the following: a. general psychokinesia ; b. epileptifonn impulse ; c. animal and organic impulse ; d. homicidal impulse ; e. suicidal impulse ; /. destructive impulse ; g. dipsomania ; h. kleptomania ; /. pyromania ; k. moral insanity. 238 STATES OF DEFECTIVE INHIBITION. General psychokinesia or impulsiveness in all directions is well illus- trated in the following case, who was a patient of mine in Morningside : E. L., set. 47, of a very neurotic heredity, a brother being epileptic, and her sisters very nervous women. In addition to this, she has had twenty years of sorrow and domestic worry, with a drunken husband who could not provide for her, and through the loss of several of her children. She has had ten children and nine or ten miscarriages. The children whom she lost all died of convulsions or hydrocephalus. The exciting cause of her illness was an abortion at two months. She was most impulsive on admission in all ways. She tore her clothes, she tried to jump out of windows, she refused food at times when she did not get what she wanted, she would do any mischief that was in her power. Be- tween those acts she was rational in speech and conduct, affectionate, and agreeable. She would be dancing, lively, and chatty in the drawing- room, apparently one of the happiest women there, and, seeing an open window, she would suddenly change in expression of face and eyes, would step towards it, and try to throw herself over. When asked about it, she would say she could not help it. She was always most impulsive at the menstrual periods, and at these times frequently had retention of urine, needing the catheter (this she had been subject to occasionally during her married life). The bromides, fattening non-stimulating foods, fresh air, baths, and constant supervision and occupation were all tried, with a gradual good effect. The impulses became less intense, and her self-con- trol more, as her bodily condition improved. She was subject to sudden feelings of what she described as "unutterable dread and woe," coming .like a flash over her and passing away as quickly. Unfortunately at first we gave her chloral and hyoscyamus at night, which I found was a mistake. She became very dependent on these things for sleep. She did much better when they were stopped. Now I never give chloral con- tinuously where there is impulsiveness. I believe that its effect is to lessen the inhibitory mental power of the brain. In about three years she had improved considerably, and was removed to another asylum ; but she is impulsive still at times, though not dangerously so. It must be remembered that all these impulses, obstinacies, violences, destructive- nesses, and suicidal attempts were most contrary to the whole habits of the life of this lady till she was forty-seven, that they then lasted more or less for nine years, and now she has got rid of them to a very large extent ; and that between those acts of want of inhibition she was one of the most agreeable and sensible persons I ever saw, and was clever, witty, and often hilarious. The next case was a patient of mine, and was well described by one of the assistant physicians here, Mr. James Maclaren. 1 I look on it as being generally impulsive and to some extent epileptiform in character. "Late one night a lady, whom we shall know as E. M., was brought to the Royal Edinburgh Asylum, laboring under great excitement, and bleeding from wounds in her mouth, caused by her attempts to swallow pieces of the glass of a cab window which she had broken. Her insanity was very early seen to be of a kind in which the leading features were 1 Medical Times and Gazette, January 8, 1876. STATES OF DEFECTIVE INHIBITION. 239 impulsive acts of a sudden and a most dangerous character to herself and to others. She is not an epileptic ; she has no delusions or hallucina- tions, or, if she is possessed with the former, they are of a kind belong- ing more to a mild state of dementia than anything else, and are fleeting ; and she has at any time only occasional and often no consciousness of the irresistible impulse which is frequently put down as the cause of danger- ous acts otherwise difficult to account for. In her the paroxysm of vio- lence has the following characters : It is periodic ; it is accompanied by always partial, frequently total unconsciousness, and consequently fol- lowed by a similar state of forgetfulness of her acts ; it is preceded by sharp pain in the head, and followed by a dull pain in the head, dizzi- ness, and confusion of ideas. There exist also certain neuroses, but these will be detailed in the course of the history of her case, which it will be well now to enter on. " She is forty-three years of age, the fifth child of a family of fourteen. Her parents are both of a neurotic type ; her father is almost totally deaf, and a brother of his died insane. That is not a very strong ' neurotic history perhaps, but, making allowances for the possible reservations of sensitive relatives, it indicates a decided tendency to nervous weakness. Her mother dwells on the border-land of insanity; she was always a person of very peculiar disposition, suspicious, unreasonable, and of an exceedingly high-strung and nervous temperament. This was her con- dition previous to marriage. Its cares and troubles, and particularly the mental and physical wear and tear involved in the bearing and nursing of fourteen children, told badly on her. Her confinements Avere severe, and after them she was subject to alarming fioodings; at her menstrual periods, too, the hemorrhage was always excessive. That all this told on her severely was noticed by her friends in her increasing debility, nervousness, eccentricity, and irritability as she advanced in years, and, to anyone who could read the lesson, was confirmed by what seems to me a very curious fact. She had, as I have said, fourteen children. The first four of these were fairly healthy, and are still living ; then came the subject of the present note, regarding whose mental and physical health we shall presently hear ; and after her came nine children, all of whom are now dead. The elder ones lived longest, and then, as the mother grew in years, and the strain on her became greater, the duration of the life of her offspring shortened. It is true that none of them died di- rectly from brain disease ; still it does not seem too much to assume, with the history I have described, that the parents were at first able to pro- create healthy offspring, that this began to fail with E. M., and that after her the strain became greater and greater, and so they produced children only in the poorest degree endowed with the power of living. The in- verse ratio between the age of the parents and the duration of life in the offspring seems too marked and definite to be due to accident or chance. So, then, in this neurotic couple we have them in their early married life transmitting to their children health, later on insanity, and ultimately a tendency to early death. "And here, forestalling its position in the history of her case, comes in another step in the descent and progressive degeneration. E. M., has become pregnant several times one child is alive, one lived a few months, 240 STATES OF DEFECTIVE INHIBITION. all the rest were born prematurely. The child which is alive is, as re- gards his mind at present, precocious and talented, writes letters in a style beyond his years, reads books on natural science, and is fond of sketching and painting, and thought exceedingly gifted by his friends. With the history I have detailed, and after this description, it is almost superfluous to say that he is stunted in body, weak, and miserable, and often barely kept alive by constant and most careful nursing. "I have now to speak of the personal history and characteristics of the unfortunate lady who is the subject of this sketch. As I have said, she was the fifth child of her parents. In her early years she was only noted for everything that was good and amiable. In this I am not taking the words of possibly too partial friends, but of others who knew her more or less intimately; and one and all bear testimony to the fact that, as regards the possession of many good qualities, she was far above the average. Kind and loving, very gentle and quiet, but apt to become emotional on trifling provocation ; devoted as far as her strength per- mitted to all good works, generous even to a fault, and earnest in season and out of season to do her duty, such is the account of her in her early days. From her earliest years religion was part of daily life, not engrafted on to her other duties, but forming the moving principle of all she did. She belonged to a devout family and a devout sect, and so, by education as well as temperament, was thoroughly and entirely devoted to sacred thoughts and duties, and was noted among her friends for the emotional fervor and power of her prayers. In ability, too, she was above the average clever, studious, and painstaking. "At the age of twenty-three she married her present husband a gen- tleman in every way calculated to make her happy. It was long before he noticed anything particularly strange in her manner or conduct. Cer- tain slight peculiarities, a morbid sensitiveness as to possible wrong-doing, occasionally excessive emotionalism, and once or twice, when in circum- stances calculated to excite or distress her (such as being in the company of uncongenial people or those of a higher social rank), a tendency to become rambling and incoherent, these were, as far as he can remember, the only facts that called for notice or excited alarm. Still it was of the slightest; for she had always been somewhat unlike other girls of her age, and inclined to strange and wayward (though serious) turns of thought and expression ; and for long the knowledge of this prevented much or any attention being paid to passing acts of eccentricity or un- wonted modes of speech. Excepting these (and they had been so slight that it is only now, on close inquiry being made, that they are recalled) she for long after she was married led the same kind of life she has been described as doing before, and was foremost in every good work and kind action. Still, it is not difficult to trace the gradual invasion of the malady of which she is now the victim. " Some years after she was married, and ten years ago, the boy already mentioned was born, but previous to that, and since, she had several times aborted. On each occasion her bodily weakness from excessive flooding was great, and her mental distress at the unfortunate issue very painful. Two years ago she again became pregnant, and, greatly to her joy, was delivered of an apparently healthy boy, and for a little while STATES OF DEFECTIVE INHIBITION. 241 the caring for it seemed to restore the balance of her mind. HoAvever, it was only spared to her for a few months, and its death and the final and marked access of her insanity occurred to her. During her preg- nancy, and for some months before, the little abnormalities I have men- tioned were beginning to become more and more marked. Her religious feelings became of the most exalted character, and her emotionalism ex- cessive. On one occasion, while walking with her husband in a fre- quented place, she knelt down and prayed for strength to bear her coming trial ; and her benevolence and generosity, always prominent features in her character, became almost unbounded, and frequently quite unreasona- ble. When the baby came, her attention was taken up with it, to the exclusion of everything and every one else. Then it was taken away, and from that time is dated the marked unmistakable arrival of the in- sanity. General excitement, an altogether morbid and excessive fear regarding her religious state and future salvation, and an excessive sensi- tiveness as to the possibility of ever having in any way wronged any one with whom she might have had dealings, were the early symptoms she displayed. Then sudden and unaccountable outbreaks of dangerous violence, attempts at self-destruction occasionally, and most destructive tendencies in every respect, rendered her removal to an asylum impera- tive. She was accordingly taken to a private establishment, where she remained for a few months, gradually getting worse and worse. During this time a hsematoma of the left ear developed itself, and ran the usual course, leading to the shrivelled and characteristic insane ear. She was brought, as I have said, to Morningside last July, with the reputation of being a patient most dangerous to herself and others, and requiring con- stant and careful watching and supervision, and she has more than justi- fied all that was said of her. She had not been long a patient before it was noticed that her case presented many points of singular and great interest. Her constant and seemingly unwearied attempts to commit some destructive act, and the care and ingenuity required to baffle these, made her an object of much thought and no little anxiety ; but quite apart from that, which is not so very rare an experience for an asylum officer, there is in her case such an amount of strange contradiction, and contrast of light and shade, as to make her a puzzling and interesting study. Instead of extracting the details of daily entries in the case- book, I will endeavor to give a brief sketch of what manner of woman she is. "First, as to her appearance she is slight and almost undersized, a very gentle-looking lady, with a pale, pretty face, light hair, and blue eyes, a singularly kind, pleasant, winning manner, and a soft, quiet voice. Second, as to her mental state free from excitement, she is what she has already been described as, thoroughly devout and good. Her memory and judgment are in all but one respect correct. Thoughts of her husband and child, bitter regret at her separation from them and at her sad calamity, a constant and prevailing desire to do what is right, and an excessive and morbid sensitiveness lest her slightest word, or look, or action may be in any way wrong. That is the bright side of the picture of a singularly pure but sadly imperfect nature. Now for the reverse, 16 242 STATES OF DEFECTIVE INHIBITION. "It is difficult in a pen-and-ink sketch to give an idea of the intense impulsiveness of her acts. I am not at all exaggerating when I say that little short of being possessed by the devil would account for her conduct. She will sit reading her Bible or some good book, or talking in her quiet, gentle way to her attendant, when suddenly, without a moment's warning, the book is flung through the nearest window, or at whatever is breakable at hand, then she makes a rush to run her head into the fire, or turns on her attendant, tears her clothes, or tries to strangle her. All this without speaking a word, except, perhaps, an occasional muttered text of Scrip- ture; but, beyond that, she keeps quite silent, and struggles on quietly but fiercely, till either exhausted, or restored by some apparent process of awakening to her former condition. Excitement, of course, there is in plenty, but it is very different from that associated with more ordinary forms of mania. There is no noise or shouting; her eyes are fixed and suffused, her face flushed, and her teeth clenched, and every muscle is on the strain; but the whole time she is perfectly quiet, and struggles on with a fixed, determined purpose expressed in her whole manner, but without wasting a word. " There is no use dwelling too long on the various destructive acts that she has committed. I might, I believe, go on for hours, and not have completed the list. Suffice it to say that there is hardly a method of at- tempting violence that the mind could conceive, that she has not had re- course to. At one time, but only for a few weeks, her acts took the form of exposure of her person, and in this, too, suddenness was the marked feature. I have seen her weeping bitterly at the sadness of her lot, and praying for some help, and while the words were still on her lips, throw herself on the ground, and pull up her dress. Once or twice about this time there was a slight increase of her general excitement, and she laughed and talked more than usual ; but as a rule the exposure was something altogether different from the ordinary suggestive act of an erotic female. This tendency to exposure, however, did not last long, and has not re- turned. "Now as to the nature of her paroxysms. Though not very definite, there is no doubt that there is a certain amount of periodicity in them. It is not hard and fast, but her attendants notice that she has, as they put it, a good day and a bad one, or two good days and two bad ones. The suddenness of their arrival has been already dwelt on. She often suffers sharp pain in the head for a longer or shorter time previous to an attack, but the transition from perfect quiet and gentleness to her wildest paroxysm is instantaneous. Then (and this seems to me a very impor- tant point in her history) there is, as a rule, entire unconsciousness and forgetfulness of what passed during an attack. I have often taken her carefully over the events of a day in which one had occurred, and in- variably found her correct and precise in every detail till we reached the onset of the seizure. Then all was a blank, and she only remembered that she seemed to faint, and then found herself lying on a sofa with an aching head, and confused and stupid. Occasionally, and if her seizure has not been very severe, she has some slight recollection of her act and of the impulse which led to it, and the latter is always a feeling of im- perative necessity that it is her duty to do as she has done ; but in by STATES OF DEFECTIVE INHIBITION. 243 far the greater number of her attacks, unconsciousness during and after o ' *~J was the rule. " There are a few physical phenomena connected with her case that I will now mention. The insane ear has already been recorded. Her tongue is tremulous and points markedly to the right side. After an attack she has a slight stutter and thickness of speech. The right pupil is more dilated than the left. During a paroxysm both pupils dilate and contract constantly and independently of each other, so that sometimes one and sometimes the other is the more dilated. Her hair is exceed- ingly dry ; her temperature is normal, with a steady increase of two points in the evening over the morning figure. Her menstruation has not returned since her last child was born. Her sensibility is at all times dulled ; during an attack it is greatly impaired. The reflex action of the cord is much dulled. 'What is the nature of her insanity? Her attacks, read alone, seem only to want one factor epilepsy to make all complete. This, though, is wanting ; she is not epileptic now, and has never been so ; and her present attacks, though bearing not a little resemblance to it, are not epilepsy. That her motor centres and the circulation in her brain are diseased, the outward signs I have told show, but that only leads us half- way, if so far. Why is it that this gentle, loving lady, who mourns her affliction so greatly, and who would fain struggle against it, so that she might return again to her husband and her child, why is it that at the very moment she is penning kind words to them, or thinking kind thoughts of them, she should be dragged into the committing of acts which she abhors, and of which she is happily unconscious ? And yet, though in her calmer moments she is oblivious, still these acts were gov- erned by a direct controlling will they had an object, and were carried to a definite end. "It is a strange condition of dual consciousness. Whether she re- members in each paroxysm what happened in the last I cannot say, but I think she does, and it is certain that she follows out trains of thoughts in successive attacks, of which she has no consciousness during a remis- sion. For instance, of late, as soon as a seizure comes on her, she makes particular efforts to get at one special picture in the room. 'When the attack has passed, this picture awakens no feelings in her at all, and she has no recollection of anything particular connected with it ; but as soon as the excitement returns, her attention fixes on it at once." In the course of three years she gradually became less dangerous, and the impulsive attacks less intense, while her mind became more enfeebled. She got so much better that she was taken home under the charge of a nurse, and is now, after seven years, almost demented, and of course quite incurable. The impulsiveness has almost disappeared. EPILEPTIFORM IMPULSE. Epilepsy, as we shall see in the psychosis commonly associated with it (epileptic insanity), tends remarkably towards impulsive acts, which will be considered under that form of insanity. By epileptiform impulse I mean those sudden impulsive acts attended by unconsciousness, which are exactly the same in character as those we are familiar with in epileptics, and yet the patients are not subject to ordinary epilepsy. Hughlings Jackson, I suppose, would call 244 STATES OF DEFECTIVE INHIBITION. them cases of mental epilepsy. Some of the acts of E. M. were clearly of this character. I have now a patient who brought on his disease by over-drinking, and who on one occasion leaped through a window on the third story when quite sober, and did not know anything about it after- wards. On another occasion, in passing the corner of a building in the asylum, he ran violently against it with his head, causing a wound five inches long, and very nearly breaking his skull-cap. He is not a regular epileptic, but he once took a convulsive epileptiform attack. His case is incurable, as he is now getting demented, and his impulsiveness is passing off. The regular use of the bromide of potassium seemed to diminish the impulsive tendency. ANIMAL AND ORGANIC IMPULSE. Under this term I include all the uncontrollable impulses towards sexual intercourse, masturbation, sodomy, rape on children, bestiality, etc. The perverted instincts, appetites, and feelings shown in urine drinking, eating stones, rags, clay, nails, etc., come under this heading too. There are few cases of mental disease where some appetite or instinct is not in some degree perverted or paralyzed. But there are cases where such things are so prominent as to constitute the disease. I have a patient who assures me that his desire to masturbate is an irresistible craving which he has no power to control. Here is a girl who rubs her thighs together to produce sexual excitement the moment she sees a man. Here is a case of nymphomania, who rushes towards any man she sees, and can scarcely be held by two attendants. I believe there are cases in which there are irresistible impulses towards sodomy and incest. Many of the men who commit rape on children are insane. I lately had to give evidence at the Carlisle Assizes about the insanity of a medical man who had tried to commit rape on three children under age in succession. No doubt he had the delusion that God had in some occult way revealed to him that he should beget a male child, and had sent the little girls to him for this purpose ; but he was practising his profession up to the commission of the act. I have referred to the case of the young woman who had an impulse to eat clay and dirt every time she menstruated. She could not help it, and had no such tendency between. A shoemaker patient in the Prestwich Asylum swallowed a few shoe-nails every day, and, what was strange, was none the worse. There is an infinite variety of such impulses. Erotomania is applied to those cases where there is an intensely morbid desire towards a person of the opposite sex, without reference to the sexual act. It is a sort of exaggerated and insane state of "being in love." HOMICIDAL IMPULSE. Homicidal impulse is often spoken of by lawyers, publicists, and ignorant persons, as if it were a thing that did not really exist, but has been set up by the doctors to enable real criminals to escape justice. Here is a letter from a former patient of mine, E. N., a medical man of perfect truthfulness and great benevolence of character, written to me when he was convalescent : MY DEAR SIR, According to promise, I have written to the best of my ability what I feel mentally. God alone knows my feelings. They are truly awful to know. I lived in continual fear of doing harm each day. I had not a moment's peace in this world. I have been in practice for twenty-three years, and have attended 2550 midwifery STATES OF DEFECTIVE INHIBITION. 245 0*968, which used to take the life out of me more than anything else. I often used, when busy, to attend to 60 or 70 patients a day at home and out, and in the winter used to average 28 a day at their houses. 1 have had no holiday for many years. I did not think I was laying the seeds of brain disease, but such has been the case in the most dreadful form. I loved my dearest wife and little ones most dearly, and my home used to be so happy and cheerful after my hard work. You are aware I had a very long illness in bed, had several operations, erysipelas, &c. Two years previous to this I had a fall on my head, which stunned me at the time. I may say I have never felt really well since the fall, though I did my practice. I had occasional strange feelings, but those were only known to myself, being ashamed to mention them ; in fact all the time, up to within a short time of coming under your care, I appeared cheerful and even jolly. But when in a train I was afraid I should jump out of the window, and when I saw one in motion I felt I must jump under it. I was afraid, when applying nitrate of silver to the throat of my patients, that I should push it down. I was terrified to apply the midwifery forceps, lest I should not be able to resist the impulse I had to drive them up through the patient's body. When opening abscesses I felt as if I must push the knife in as far as possible. When I sat down at my own table I used to have horrible impulses to cut my children's throats with the carving knife. At the sight of pins I had a feeling as if some had got into my throat, and I could not divest myself for some time of this feeling. I had other strange feelings which I can hardly describe. Whenever I saw a knife, razor, gun, etc., I was afraid I should do harm by a sudden impulse, the will having hardly the power to resist. I took opium several times from no deliberate intention, but by a sudden impulse that I could not resist when I was working with it in the surgery, but I vomited it. My brain feels quite dead, with no feeling in the scalp ; my eyes seem as if some- thing were dragging at the optic nerve continually. In the left I have a most unpleasant feeling to bear, and I cannot see distinctly with it. There appears to be something floating in front all the time like a dark shade. I should say I am, and have been, suffering from homicidal monomania and moral insanity, and have been since June last, although a part of the time doing my practice and living with my family. I thought I could shake it off, but such was unfortunately not the case. Thanking you most sincerely for the kindness and attention shown to me since I have been a patient in this asylum, I am, dear sir, yours faithfully, E. X. Now this is either a tissue of lies, or the thing homicidal impulse exists. This unfortunate man had placed himself in the asylum of his own accord, and he took a gloomy view of his prospects of recovery. I did not do so, but assured him he would recover, and adopted every means for that purpose ; gave him tonics, got him employed and interested, made him live in the fresh air, and go to all sorts of amusements in the asylum and out of it. I am glad to say he recovered, and went into practice, and unfortunately got as much to do as ever, and relapsed. This time he showed his impulsive tendency and loss of inhibition by taking to drink, which looked like a symptom of his brain disorder. By temperament he was a sanguine man, strong, hearty, robust, and jolly. In fact he was a perfect Mark Tapley in his unfailing cheerfulness under difficulties and disasters. He was an immense favorite with the ladies here, and to see "the doctor" being taught by them to dance a Scotch reel was a sight far away from any suicidal or homicidal idea. Yet in the midst of this a dark shadow would sometimes cross his face, and he would say to me, " Oh, doctor, these strange feelings ; if they would only keep away I should be as happy as I look." This is merely one case, but it is a typical one. E. N. had no insane delusions, he could reason well ; affectively he was fond of his wife and family and friends ; he had not a cruel or criminal disposition quite the reverse ; he had no outward excitement, no signs of outward depression like an ordinary melancholic patient ; his mind was not enfeebled, yet he 246 STATES OF DEFECTIVE INHIBITION. wanted to kill his patients and his children, and had much difficulty in restraining himself from doing so, and he actually could not restrain himself from suicidal acts. All these feelings were connected with an original heredity to mental disease, with a brain exhausted by hard work and no rest, and with a running down of his general vital power by the bodily disease he had lately suffered from. They had as their accompani- ments those marked sensory and special sense feelings described in his letter, which were really an essential part of his trouble. They disap- peared under rest, change, proper medical and moral treatment. The whole affection was just like many other diseases in its causation, inception, and recovery. What room, therefore, is there for doubt that such a disease exists ? That the theory of uncontrollable homicidal impulse should have been used in courts of justice to screen real murderers or would-be murderers, is surely no reason for disbelieving important facts of disease. It is our duty as medical men to examine carefully the evidence in every case where a homicidal impulse theory is set up to explain crime, to look on any such case suspiciously perhaps, to search for other symptoms and causes of mental or nervous disease accompanying it, but we must not be frightened by the lawyers into blinking real facts and real disease. Homicidal impulses in a mild Avay are very common indeed in the be- ginning of mania and melancholia. Patients feel as if they must kick and strike those near them, and they often do so. It is a relief to them to do so. Such impulses are often part of the nervous disturbances that accompany puberty, disordered menstruation, childbirth, lactation, and the climacteric period in women. I once saw in gaol a girl of thirteen, whom I had no doubt had without motive killed a child entrusted to her care, though there was no legal proof of it. Margaret Messenger, a little girl of thirteen, was proved at the Carlisle Assizes, 1881, to have drowned a child of six months, of which she had charge, and she had previously killed its brother. Like all such cases, she had no motive, and showed no mental excitement or depression. She could not be made to realize the gravity of her situation or the awful nature of the crime she had committed. This paralysis of feeling and of fear is very char- acteristic of such cases. She was described as " a typical country girl of her age, fresh, tidy-looking, and fairly intelligent." She was quite composed through the trial. After her conviction she confessed that she had killed the brother by throwing him into a well, in which it had been supposed he had fallen accidentally. I had a patient last year, E. N. A., a lady with a child five months old when I saw her, and who, on medical advice, left her home on account of a morbid dislike to her husband and child, and homicidal impulses towards them. During her pregnancy she had the same kind of dislike to her mother. She deplored these morbid desires to kill her husband and child intensely, because she was devoted to them, and a most affectionate woman. She had suicidal impulses too, but not so strong. These were not the only symptoms of disease. She suffered from dull headaches, twitchings on the right side of her face when she spoke, impaired sleep, fever, slight alburninuria, aggravation of all her symptoms in the mornings, screaming fits, want of appetite, thin- ness, and a pigmented skin. Through change, absence from home, milk STATES OF DEFECTIVE INHIBITION.' 247 diet, exercise in the fresh air, iron, claret, and pleasant companionship and travel, she recovered in about four months, getting stout, fresh-col- ored, and menstruation becoming regular. I have referred to the case of B. R. (p. 112), a climacteric case, and her tendency to kick, strike, and pinch her fellow-patients in the morning only, while in the evenings she would be cheerful, would dance, and enjoy herself. I have now a man, E. N. B., with a neurotic heredity, an uncle being epileptic, who, when sitting at a window, dropped a big stone on to the top of the head of a casual passer-by, against whom he had no ill-feeling whatever. After he was sent to the asylum we could see nothing wrong with him till one day he tried to stick a dung fork into an attendant. He seemed to recover, and, after a long time of probation, he was discharged, but very soon ran after a relation with an open knife. He was sent back to the asylum, showed no signs of insanity at first, and then his mind grad- ually became enfeebled, and he is now nearly demented, just as he would have been had his attack been one of mania. Homicidal impulse is thus seen to end in dementia if it lasts long, like any other kind of mental disease. I have even seen a homicidal stage in the beginning of general paralysis. SUICIDAL IMPULSE. I am speaking here, remember, of suicide as an impulse unaccompanied by any marked mental depression or delusion. The following two cases exemplify what I mean : E. 0., a young man of eighteen, of nervous heredity, with no par- ticular cause of mental or bodily disturbance, except perhaps an unre- quited love fancy for the scullery-maid. He being an assistant to a butler in a gentleman's family in Cumberland, seemed in good health, in good spirits, and was washing the dishes after lunch one Sunday. His master, from the dining-room, heard a peculiar sound in the pantry, and, going to see what it was, found E. 0. hanging by the towel with which he had been wiping his dishes, his face livid, and nearly dead. After being taken down he was unconscious for some hours, and then confused in mind for a day or two. He was sent next day to my care at the Car- lisle Asylum, and I found him confused, and his memory defective. He could give no account whatever of the suicidal attempt, and was rather inclined to deny it, but the evidences of it Avere well marked on his neck and face. There was no mental pain, and no delusion. He did not sleep very well. He was sent much into the open air, and was ordered a little bromide of potassium. In a week there was not a trace of any mental defect whatever. He was not a strong-minded youth, but not imbecile. He maintained through many cross-questionings that he never had a conscious intention or thought of putting an end to himself in his life ; that he remembered events quite well up to a certain moment on the Sunday he was washing his dishes, but after that he had no recollec- tion of anything whatever till the evening. I had no reason whatever to doubt the correctness of his statements, which were confirmed to me by the butler. He kept quite well when last I heard of him. E. P., a young professional man of thirty, whose father had been sub- ject to "depression of spirits," and who had had chorea in his youth, but who was clever, cheerful, good principled, religious, and successful. He was happily engaged to have been married in a fortnight. He had been 248 STATES OF DEFECTIVE INHIBITION. spending the evening with some friends, and was in first-rate spirits. No melancholy or morbidness whatever had been seen in him. He had remarked to some friend casually some weeks before that he had to hold his head in a particular way or he saw things double. He took a hearty supper, and went to his bedroom. In the morning his body was found suspended to a cupboard door by the worsted cord of the window curtain. He had undressed, and then, evidently without preparation or contrivance of any kind, taken the cord, Avhich was sewn in a circle, thrown it as a loop over the top of the half-open door, put the other end of the loop under his chin, and, pulling up his feet, suspended himself. There was a strong presumption that it was not a conscious, premeditated act. We found a large ossified spiculum of bone projecting from the dura mater into a convolution at the vertex at the junction of the anterior with the middle lobe, the arachnoid thickened, and the whole brain intensely con- gested. I considered the case one of unconscious suicidal impulse of an epileptiform nature. Such irritating spicula of bone of course often cause ordinary epilepsy, and this is not the only case of impulsive in- sanity in which I have met with the same pathological appearances. Those were cases of morbid suicidal impulses accompanied by uncon- sciousness. Such cases are rare. But cases like the following are very common in the experience of most medical men. The classical tedium vitce was somewhat of this character, looked at medico-psychologically. E. P. A., a man of fifty-five, who had been healthy and lively. For some months his enjoyment of life has been less intense, but he has had no real mental pain. For a few weeks he has had a strong impulse to take away his life, and the sight of a knife at once suggests this to his mind at any time. He has no delusions whatever about being wicked, etc. He deplores the feeling, and it annoys him, and he thinks himself "a fool" for harboring "such nonsense" in his mind, but he cannot help it. The only thing wrong with him is this, that he cannot sleep very well. Change of air and scene, after about two years, seemed completely to drive away the suicidal feeling, but his mental condition after it passed off was somewhat senile, his ambitions, desires, and enjoyments being toned down, and all the keen edge of his life taken off. When the impulse is towards self-destruction, even the lawyers do not deny its existence or try to reason facts away. And they cannot attri- bute any sufficient "motive" for such persons as E. 0. and E. P. putting an end to themselves, though this notion of a "motive" for suicide seems ineradicable in the public mind. Who ever saw an account of a suicide in a newspaper without an explanatory remark that " the motive for the rash act has not been ascertained ?" It is impossible to tell how many of the sixteen hundred annual suicides of England are the result of mere impulse, apart from mental depression, delusion, or alcoholism. It is common to find the suicidal and homicidal impulses combined, as in the case of E. N. (p. 244), to which I have referred. DESTRUCTIVE IMPULSE. In childhood there exists, from pure accumu- lation of motor energy, that must be let off somehow, a desire to play, to romp, to move, and to destroy. Most people experience a morbid muscular activity when they have " the fidgets," and few people but have the feeling sometimes that they would like to break glass or smash some- STATES OF DEFECTIVE INHIBITION. 249 thing. In many forms of mania and in excited melancholia we have destructive tendencies as one symptom of the general psychosis. In high emotional tension women often feel as if they must cry or break some- thing, and many women in prison take regular periods of "breaking out," during which they tear and destroy clothes and property without regard to punishment or to consequences. In the first stage of general paralysis the morbid motor activity usually takes the form of tearing, and it is common for such cases to have all their blankets torn to shreds every morning, and their clothes during the day. But the same uncontrollable desire to tear or break may exist alone, without much outward exaltation or depression. I have now a young man of twenty-five, E. P. A., whose mother was insane and his brother paraplegic, who for two years required the constant vigilance of an attendant to prevent him breaking windows and tearing his clothes. He actually broke over one hundred small panes of glass, and tore one hundred and fifty pairs of trousers. The reason he assigned for this was that he could not help it, and that it was " my conscience checking me " that did it. He was quite sprightly and jolly, would work in the garden, would dance at the ball as lively as anyone, and was never suicidal or homicidal, yet when he saw a window near, he would eye it as if fascinated, and, if he had a chance, would spring at it and smash it, or throw something at it. He said it gave him great relief when this was done. He seemed to grow out of this tendency as he became more demented, which he did gradually. The habit of mas- turbation increased the tendency in him, and hard work in the garden ordinarily diminished it. The bromide of potassium and cannabis Indica kept it in check. I show you another patient, F. F., of twenty-two, who suddenly when at sea took "smashing fits," the description of which by Dr. Logie, his family medical man, was as follows : " His bodily health is good, but he is subject to sudden fits of something like insane impulse, continuing sometimes for a few minutes only, and at others for a whole day. During their continuance he has no control over his actions. He says he knows he is doing something which he ought not to do, but he cannot help it. At one time the presence of the fit is manifested by his roaring aloud and using very bad language ; at another he will suddenly jump up, seize a chair, dash it with violence on the table, smashing to atoms dishes, cups, and saucers, or whatever else may happen to be on the table. When in these states he is exceedingly violent. AA f hen interfered with on one occasion he knocked his mother down, and on another threatened to shoot his father, who was trying to control him. Unless when the fits are on him, he is perfectly quiet and reasonable. He believes that the fits are occasioned by a person who has power over him, and can make him do as she likes, and that she first obtained that power by putting something in his tea." After admission he would be rational and self-controlled before these attacks, and again after. He still has the ten- dency, though it is less intense and less frequent. As the period of adolescence is passing into manhood and his beard is growing, I expect him to recover. I watched him one night at a dance. He looked absent- minded, and aimlessly restless. I spoke to him, and he answered me 250 STATES OF DEFECTIVE INHIBITION. rationally. He looked pale, and his eyes were glistening. He stepped towards a window, and suddenly smashed it with his hand, causing a wound. At once he seemed to get calm and quiet, and felt relieved. We had on two occasions as a patient in Morningside a man named James Morrison, who at intervals of several years had left his home in a Fife village, where he worked as a weaver, and had gone to Glasgow once, breaking some windows in the Cathedral, and to Edinburgh twice, breaking some large plate-glass windows in shops, always quite coolly, by throwing stones at them. After coming to the asylum we could scarcely ever detect any symptoms of mental disease. He seemed to have expended all his morbid energy in the one act each time. He was a man of neurotic heredity and good character, who had no motive for getting into goal. He always said he could not help smashing windows ; that the desire to do so used to come on him in his home in the Fife village, along with a restless, unsettled feeling ; that he did not break the windows in the houses of his village because they were too small and " not worth breaking." It evidently would have given no satisfaction to his morbid desire to break them. I presume his was just a strong and uncontrollable form of the feeling which many men have who stand before a big plate- glass window with a cricket ball in their hands. DIPSOMANIA. This is a misnomer ; we do not mean an insane craving to drink. What is meant is a morbid uncontrollable craving for alcohol and other stimulants. What we really want is a good word to express the cravings for all sorts of neurine stimulants and sedatives, as well as alcohol. The confirmed opium eater, the inveterate haschisch chewer, the abandoned tobacco smoker, are all in the same category. No medical man who has been long in practice can doubt for a moment that there are persons whose cravings for these things are uncontrollable, and who have therefore a disease allied to all the other psychokinesis. Particularly the morbid craving for alcohol is common, and so intense that men who labor under it will gratify it without regard to their health, their wealth, their honor, their wives, their children, or their soul's salvation. Certain causes predispose to it. These are (1) heredity to drunkenness, to insanity, or the neuroses ; (2) excessive use of alcohol, particularly in childhood and youth ; (3) a highly nervous diathesis and disposition combined with weak nutritive energy ; (4) slight mental weakness con- genitally, not amounting to congenital imbecility, and chiefly affecting the volitional and resistive faculties ; (5) injuries to the head, gross diseases of the brain, and sunstroke; (6) great bodily weakness and anaemia of any kind, particularly during convalescence from exhausting diseases ; (7) the nervous disturbances of menstruation, parturition, lacta- tion, and the climacteric period ; (8) particularly exciting or exhausting employments, bad hygienic conditions, bad air, working in un ventilated shops, mines, etc. ; (9) the want of those normal and physiological brain stimuli that are demanded by almost all brains, such as amusements, social intercourse, and family life ; (10) a want of educational develop- ment of the faculty and power of self-control in childhood and youth ; (11) the occasion of the recurrences in alternating insanity, or the beginning of ordinary insanity ; being coincident in a few of these cases with the periods of depression, but mostly with the beginning of the STATES OF DEFECTIVE INHIBITION. 251 periods of exaltation ; (12) the brain weakness resulting from senile degeneration. More than one of these causes may, and often do, exist in the same case. The neurine-stimulant craving is nearly always associated with impulses or weaknesses of control in other directions in by far the majority of the cases, while there may be no insane delusion. Yet all the faculties and powers that we call moral are gone, at all events for the time that the craving is on. The patients lie ; they have no sense of self-respect or honor ; they are mean and fawning ; they cannot resist temptation in any form ; they are erotic, especially at the beginning of an attack ; they will steal ; the affection for those formerly dearest is suspended ; they have no resolution, and no rudiments of conscience in any direction. The common objection to reckoning such persons among the really insane is that, though they have brains predisposed by heredity, they have often brought this condition on themselves by not exercising self- control at the period when they had the power to do so ; but this applies to many cases of ordinary insanity. Another reason is that, when deprived of their stimuli for a short time, they are sane enough in everything except resolution not to take to them again. The effect of the excessive use for a long period of nerve stimuli of all kinds is to diminish the controlling power of the brain in all directions, and to lower its highest qualities and finest points. The brain tissue is always so fine, so delicate, and so sub- tile-working, its functions are so inconceivably varied and so high, that under the most favorable circumstances it runs many risks of disturbances of its higher functions. But when we have a bad heredity, a bad educa- tion, and a continuous poisoning with any substance that disturbs its cir- culation and paralyzes its capillaries, that excites morbidly its cells, that proliferates its neuroglia, thickens its delicate membranes, and poisons its pure embedding lymphatic cerebro-spinal fluid, we cannot wonder that its functions become impaired and are not fully or readily resumed in all things. The unfortunate peculiarity is, that while we may restore the bodily and even the nervous tone so far as muscularity, sleep, and sensory functions are concerned, we have the utmost difficulty in restoring the higher functions of self-control and morals in some cases. A dipsomaniac when at his worst is readily recognized to be so really insane as to be in a fit state to be placed under the control of others for proper care. When he is at his best after a few weeks' compulsory deprivation of his brain- poison he is so like the rest of the world in all essential things that it is most difficult to see how laws can be framed in the present state of public feeling and medico-psychological knowledge to deprive him of his liberty. We cannot regard the drink-craving alone. We must be prepared to deal with the opium eater, insane smoker, chloral taker, gambler, and even many thieves and insane speculators. The state of brain in all these is the same in its essential nature. It would be inconsistent to provide against and try to cure the one without including the others. I shall noAv show you a typical dipsomaniac, F. B. His mother had been melancholic at one time, and her family was a neurotic and insane one. He was of a nervous temperament from the beginning; a flesh eater from a child ; precocious and quiet, but not dogged in application ; vain to an almost morbid extent, and in some points not endowed with 252 STATES OF DEFECTIVE INHIBITION. common sense. At puberty he had a slight attack of chorea. About seventeen he showed keen social instincts, but no realization of the serious- ness of life. Especially the nisus generativus was periodically so strong as to be difficult of control, and he did not control it. Being a "jolly fellow," and mixing with such, he took alcoholic stimulants of all kinds very freely, and showed a very great fondness for them. He occasion- ally got drunk. About twenty he was addicted to bouts of drinking and whoring, which came on periodically, and seemed to pass off and leave him fit for his work. He was ashamed of them afterwards, and I believe very often by his volition and self-control did not at this time indulge in them even when he craved them. At twenty-two he was very distinctly worse. He had less power of applying himself to anything. He took almost regularly recurring periodic bouts of drinking, during which the craving for alcohol was intense and quite irresistible. I have known him drink turpentine, eau-de Cologne, and chloroform when he could not get alcohol. Hewas nervous, tremulous, and unable for any kind of work while the fit lasted. He would lie, cheat, steal, and associate with the lowest characters at those times. When he recovered he was facile, lacking in conscientiousness, and somewhat unveracious, though a charm- ing companion. All sorts of things were tried long sea voyages, a colony, isolation in a doctor's family but no permanent improvement was produced. He sank lower and lower mentally and morally, till at thirty he was really weak-minded and unfit for respectable people to asso- ciate with, and unable to do any work of any kind. Not an atom of self-respect was left in him. He is now, at forty, in a mild state of de- mentia. That is one type of dipsomania. I have only known two such who recovered. Treatment is usually begun too late. In reality, youths with such a constitution of brain should live on milk and farinaceous food in childhood, should not be brought up in cities, should never touch al- cohol, should be trained in strictest morality and with little temptation, should marry early if possible if the drink-craving has not been awakened, and should not lead exciting, hard lives. After they have become dipso- maniacs, in the present state of the law that does not allow legal inter- ference with their liberty I say it with deliberation the sooner they drink themselves to death the better. They are a curse to all who have to do with them, a nuisance and a danger to society, and propagators of a bad breed. The essential texture and working of such brains are bad, just as much, but in a different way, as an ordinary insane man's. Such cases may be called dipsomaniacs by natural development. There is an essential weakness of mind underlying that sort of case. Here is another kind of case. F. C., a married woman ; the mother of a large family. She was quite well, and showed no drink -craving till she was thirty. When pregnant with her sixth child (the three pre- vious children having been all born and suckled within five years, all her labors being hard, and in one case with post-partum hemorrhage) she be- came quite suddenly changed mentally and morally. She got careless, slovenly, lazy, self-indulgent, neglectful of her children and family duties, evidently not so fond of her husband and children, irritable, and un- truthful. In addition to all this she took to smoking and drinking. STATES OF DEFECTIVE INHIBITION. 253 This continued till three months after the birth of her child, when she became slightly depressed for two or three months, and Avas then quite well till next pregnancy. The same condition that I have described came on again. It has come on and gone off with a certain regularity fifteen years now. I expect it to cease at the climacteric period. She has had, by the way, two attacks of convulsions. This form of dipsomania I look on as one form of alternating insanity. Here is a third kind of case. F. D., an educated professional man, whose heredity I could not ascertain, who had worked very hard, and had been most successful; a man of power, of a nervous, enthusiastic temperament, and of great natural endurance and capacity for work. He took too little holiday, and unfortunately, from a mistaken idea of its real use, took to alcohol to restore his weariness, keep himself up to his work, and produce sleep. It seemed to do all those things at first. But he soon could not work or sleep without it, and it lost its power, so that he had to take more and more, and often er and oftener. At last he got absolutely dependent on it, but it would not make him work enough. He took big doses, and had an attack of acute alcoholism. After this he pulled up, but only for a time, and he took to it again with the firmest resolve to restrict himself to small doses. In six months he was as bad as ever, and had several severe alcoholic convulsions. This occurred again and again, and he became temporarily maniacal, with all the motor symptoms of alcoholism. He got better of this, took to drink again, and had convulsions, mania, and alcoholism. Morally he was weak, un- truthful, and unreliable, but never so bad as the youthfully developed dipsomaniac F. B. He died, after a few years, demented, and with par- tial paralysis of the diseased membranes and arteries and the softened degenerated brain neurine that usually follows the continuous excessive use of alcohol. That is a case of dipsomania caused simply by the excessive use of alcohol in an originally good sound brain. There is much hope in such cases if taken in time, if they can then be made to see the importance of absolutely abstaining from alcohol altogether. The continuous use of the bromide of potassium I have found most useful in such cases. It dimin- ishes the intensity of the craving, and lessens the excitability of the brain. Never in this nor any other class of insane drunkards think of tapering off the drink. Knock it off at once, and completely. I never saw any bad result from this. The moral treatment and management of dipsomaniacs is now one of the most unsatisfactory things a medical man has to undertake. The relations and friends of some patients will implore you to do something or recommend something; yet nothing can in most cases be done. Lu- natic asylums are certainly not the proper places for them, and when sent there they cannot be kept long enough to do them any good. What we want is an island where whiskey is unknown ; guardianship com- bining authority, firmness, attractiveness, and a high bracing moral tone; work in the open air; a simple natural life; a return to mother earth and to nature ; a diet of fruits, vegetables, bread, milk, eggs, and fish ; no opportunity for one case to corrupt another ; and suitable punishments and deprivations for offences against the rules of life laid down all this 254 STATES OF DEFECTIVE INHIBITION. continued for several years in each case, and the legal power to send pa- tients to this Utopia for as long as medical authority determines, with or without their consent. That would be the ideal mode of treatment. In real life the best thing we can do is to send our cases to distant farms or manses, or doctors' houses in remote parts of the Highlands and Islands under a firm moral guardian. I am very sceptical about institutions for dipsomaniacs where many of them are together. In that case the moral atmosphere tends to be low, the patients keep each other in countenance, you cannot restore the sense of shame and of self-respect, and they plot and fan each other's discontent. If an ordinary dipsomaniac does not want to be cured, no power in heaven or earth will cure him. In that case, no law permitting forcible seclusion will do any permanent good in the way of cure. It is easy in many cases to produce a temporary amendment, to rouse a sense of shame and regret for the time being ; but what is the use of that when they return to the world, if there is no power of inhibition against the first glass, and when the first glass creates an irresistible craving for the second ? KLEPTOMANIA. This interesting variety of uncontrollable impulse seldom exists alone without other moi'bid mental symptoms being present. The mere desire to appropriate for one's self what does not belong to one is an instinct strongly developed in the animal kingdom, in primitive and savage man, in children, and in many kinds of mental disease. Imbeciles appropriate and hide what they fancy, just as jackdaws do. The desire is there, and there is no inhibition. In general paralysis appropriation of all kinds of things is most common. I have now a patient who every day stuffs his pockets with rags, stones, bits of glass, broken pottery, etc., till he looks as if he had a meal bag on each side of him. Every night his attendant throws these things away, but the process is repeated next day. I once found a general paralytic trying to stuff the coal- scuttle into the backside of his trousers. Some demented patients steal everything they can lay their hands on. I have never myself met with a pure case of kleptomania without other mental symptoms. PYROMANIA. A good deal has been written on the morbid tendency to set things on fire. There is no doubt that it exists, but there is more doubt about its existing alone without other symptoms of insanity. I now show you a marked example of the disease, combined with some melancholic depression of mind, and with one or two delusions. F. E., get. 59 on admission. The cause of her attack was mental distress at a sister's becoming insane and dying in the asylum. She was melancholic and suicidal on admission, and had delusions that she had been guilty of great crimes. A first she tried to commit suicide by tying pieces of cloth round her neck to choke herself with. In six months her mental condition assumed the form of an intense desire to set things on fire, to set her clothes on fire, to burn the house. She became impul- sively violent at times. She set fire to her hair one day, another day rushed into a dormitory, shut the attendant out, shovelled the live coals from the fire on to a mattress, threw herself among the burning mass, and pulled another mattress on the top of her, severely burning herself, and, in fact, nearly losing her life. She sits saying to herself, " I maun mak them low" (I must set them on fire), day by day. In four years STATES OF DEFECTIVE INHIBITION". 255 this impulse to burn became less intense, and she was more enfeebled in mind, and in about six years after admission she was thought to have got quite over it; but one night she went into a dormitory and set all the bedding on fire from a gas-jet, but did not attempt to burn herself or her clothes. Now, at the end of nine years, she is demented, but still has the remains of the old impulse, though in a very slight degree indeed. I was once asked to see a man called J. F. Wilson, who was in the Edinburgh gaol on a charge of fire-raising, having at two places set fire to stackyards. I found that he had once undergone punishment for a similar offence, and that on being taken up on this occasion, when going with the police sergeant to the station, he remarked on passing a big haystack: "That would make a fine blaze." I found him to be a case really of delusional insanity with a good deal of general enfeeblement of mind and hallucinations, hearing voices telling him to commit rape, and the voices and screams of old friends often in the night. In addition to a desire to set things on fire, the sight of which gave him pleasure, a female he had once known often said to him, when he was thinking of doing so, "If you are to do so, do it quickly." I considered the causes of his disease to have been heredity, drinking, and syphilis. He had suffered from one attack of mania, for which he had been in Colney Hatch Asylum. I did not think he had any chance of recovery. He was found insane, and sent to the lunatic department of Perth Prison, but was discharged recovered. Within a few months he again set some stacks on fire. This time I could discover no symptoms of insanity about him, but a slight general mental enfeeblement, and he received sentence as an ordinary criminal. The majority of the cases Avhere an impulse to set things on fire is the chief symptom of mental impulse have been young persons about the age of puberty and adolescence, of strong nervous heredity. In such patients it is merely another manifestation of that morbid impulsiveness and "in- stinctive" action, of which the homicidal impulse that I have described is the most marked example. MORAL INSANITY. The morals and affections are lost or become altered in many forms of insanity. The question is Have we any examples where, from disease, a man who had up to that time been moral and conscientious, and obeyed in his conduct the laws and the social observances, had lost his moral sense while he retained his intelli- gence and reasoning power, having no mental exaltation or depression, and in consequence of that diseased moral condition, spoke and acted immorally? Further comes the question Can he, when the diseased condition is cured or recovered from, regain his former morality in feeling and conduct? I have no hesitation whatever in answering both questions affirmatively, because I have seen such cases. It is not a question of theory, but of fact. A third question arises Do we meet with children so constituted that they cannot be educated in morality on account of an innate brain deficiency, rendering them incapable of knowing the differ- ence between right and wrong, of following the one and avoiding the other, of practising checks on inclination, of exercising self-control or obedience to the laws of God and man, of any love and cultivation of the good, or any dislike of evil? Such moral idiots I, like others, have met 256 STATES OF DEFECTIVE INHIBITION. with frequently. Persons with this disease, and persons with this want of development, we say labor under moral insanity. Conscientiousness, the sense of right and wrong, is, to a large extent, an innate brain quality. We see this in children from the earliest age. Some have it strongly, without teaching or example; others have it spar- ingly, and need the most assiduous care to develop it. I have referred to a morbid conscientiousness that is sometimes seen at early ages in children, and in some of them is followed by a paralysis of the sense at later periods of life. I was once consulted about a boy (F. H.) of ten, not an idiot or an imbecile, and quick intellectually, who could not be taught morality. He really seemed incapable of knowing the difference between a lie and the truth, or, at all events, he never could be got to avoid the one and tell the other. And he lied without any temptation, and with no object to be gained. His statements as to the most ordinary matters of fact were never believed, merely because he made them. He stole; he had little proper affection for his brothers and sisters and parents; he was incapable of the sense of shame. When punished or scolded he became mentally paralyzed and in a condition of stupor, in- capable of knowing or doing anything whatever. As this boy approached puberty he developed some moral sense. His grandmother had been insane. I knew a boy, F. L, one of a very neurotic family. Grand- mother insane, father a dipsomaniac, and two sisters melancholies, and other two with various neuroses, who was untruthful and immoral instinc- tively. No one who knew him ever believed a word he said. He stole, he had small affective power, and he never seemed to see why anybody should be offended at acts of immorality or dishonor. He was carefully and religiously brought up. In after-life he turned out a selfish and negatively immoral man. He never paid any debt that he could help, and he borrowed from everyone he could. He treated his relations badly. He on several occasions did public acts . that might have brought him under the cognizance of the criminal law. He did these things in a stupid way, as if he himself was quite unconscious he was doing wrong. Such cases are the bane and disgrace of their friends and families, and the skeletons in the closets of their relations. Nothing can be made of most of them morally, any more than a genetous idiot can be converted into an active-minded man. Wrong is right to them : they prefer lies to truth, immorality to morality. I knew one such case (F. K.) who was continually breaking every commandment of the decalogue. He went through a form of marriage with four women, to each of the last three having told that he was unmarried, and I just saved the fifth by a few hours from going through a form of marriage with him ! Several members of his family had been insane, and others subject to various neuroses. He took his heredity out in immorality. The occurrence of moral insanity as a disease in those who have pre- viously had the moral sense, and have exercised self-control, without at the same time the presence of morbid mental exaltation of some sort, is not in experience so common as the want of a moral sense from con- genital deficiency. Pritchard quoted many such cases, and vividly de- scribed the disease, but I should place most of his cases in my category of simple mania, like C. B., C. C., and C. F. (pp. 128, 131, 133). THE INSANE DIATHESIS. 257 There was distinct mental exaltation along with the loss of moral sense. But in the following case there was no apparent exaltation : F. L., set. 37, a lady of mixed race, her father having been English and her mother of a distinguished Hindustani family. Up to the age of thirty she had been as other women, had married, borne children, and conducted her affairs discreetly under many difficulties. About that time she entirely changed, morally and affectively, without intellectual per- version and without mental elevation or depression. She went to a distant part of the country, where she was not known, got acquainted with various persons there, especially fascinating one poor gentleman of a benevolent disposition. She said she was the heiress to vast estates and to a title. Through this gentleman she got introduced to other persons, some of whom believed her impossible stories. She carried out impos- tures most daringly and cleverly. She got introduced, or introduced herself, to one great nobleman after another. She imposed on the Secretary of State for India by sheer impudence and lies. She went to a public meeting where she knew a nobleman of philanthropic zeal was to speak, told the doorkeeper she was an intimate friend of his, and was shown into the private room reserved for him ; told him when he arrived that it Avas she who was the great support of the movement about which he was to speak in the district, was taken and seated by him on the platform, and so got introduced to many other distinguished persons. She raised large sums of money, amounting altogether to many thousands of pounds, on no security whatever. She furnished many houses most extravagantly at the expense of trusting upholsterers, and she got posses- sion of jewellery to a large amount. To one person she was a great literary character (and she did have printed, at other people's expense, a volume of other people's poems as her own), to another she was of royal descent, to another she had immense expectations, to another she was a stern religionist. All this was the prelude to an attack of hysteria, brain softening, and spinal disease, of which she died in a year, demented and paralyzed. And one of the most astounding things was that her first benevolent patron believed in her to the last, came to see her in the asylum, and was going to write her biography as that of the most won- derful woman he had ever come across this being a decent middle-class man, who by his honest industry had made a small fortune, and had lost .3000 of it through her. And he was counted sane and she insane ! THE INSANE DIATHESIS. A description of the general symptoinatological forms of mental dis- orders would not be complete without reference to a condition of mentali- zation which has been called the insane diathesis. Maudsley, in this country, and Morel, in France, have described it better than any other authors. The great difficulty about its description is that we find few cases of this condition alike, and its special manifestations in different cases are as multiform as the human faculties, and as complex as different combinations of unusual developments of those faculties can make it. There are certain human beings characterized through life by striking 17 258 THE INSANE DIATHESIS. peculiarities, eccentricities, originalities in useless ways, oddities, dispro- portionate developments, and nonconformities to rule, these things not amounting to mental disease in any correct sense, and yet being usually by heredity closely allied to it, or by evolution ending in it at last. The children of insane parents, or some of the members of families who have developed many neuroses, are most apt to exhibit the symptoms of the insane diathesis. Its symptoms are so various that they cannot be briefly described. One has merely to read the works of the modern psycho- logical novelist to find the type of person I refer to in abundance. No one has lived long in the world without meeting in the flesh many examples of it. And there have been enough examples of it in the real lives recorded in biographies, ranging from the inspired idiots to the inspired geniuses among mankind. We may safely reckon Chatterton, De Quincy, Cowper, Turner, Tasso, Lamb, and Goldsmith, to take a few men of genius, as having had in some degree the insane temperament. We find some such persons strikingly original, but not reasonable; different from other men in their motives, in their likings, in their ways of thinking and acting to such an extent that human society would at once come to an end were all others like any of them. They are all in the highest degree "impracti- cable" and "unwise" in the conventional senses of those words. Some are abnormally sensitive and receptive, others abnormally reactive. Some are subject to influences and motives that are absolutely unfelt by ordi- nary men, such as hypnotism, sympathy with animals, etc. Most of the spiritualists, thought-readers, and clairvoyants who are honest, as well as many "Bohemians," are of this class. The actions of most of them may be described as instinctive. They do not find their way to lunatic asylums, but their friends often have to consult our profession about them, especially in youth. And fortunate would it be for many of them if the doctor had the direction of their upbringing on physiological and medico-psychological principles, instead of the schoolmaster on doctrinaire and purely mental ideas. How much unhappiness might have been saved in the world had this been done! For if there is any distinguishing feature of many of them, it is the capacity to be miserable. Nothing reconciles one so to the abundance of commonplaceness and stupidity in the world as a study of the lives of some of these persons. And surely our profession will in the future be able to apply its knowledge of brain function and development and the laws of heredity towards making the most of such lives, strengthening the weak points without forcing down the strong ones, saving from misery and ruin without depriving humanity of their originality and intenseness. I have one case in the asylum that may be counted as of the insane temperament. F. M., the son of an eccentric father, who could not get on as a student, because he would insist on studying, not what was prescribed, but what he liked, whose knowledge is prodigious on all subjects the only man whom I ever knew who had read through the Encyclopaedia Britannica, and lived but whose common sense is infinitesimal. I never saw any man, sane or insane, who could "make such a fool of himself," in an ordinary com- pany of ladies and gentlemen. He has most original ideas as to the future politics of Europe, founded on a profound study of the mental THE INSANE DIATHESIS. 259 characteristics and capacities of the races who inhabit it. Yet he will get up and sing "My Pretty Jane" in a large company, out of tune and out of time, and so ridiculously that there is scarcely a dement in the asylum who will not laugh at him, and call him "daft." He is totally unfitted to "get on" in the world in any way. I presume it was this that drove his friends, after many trials elsewhere, to send him to a lunatic asylum, as the only place fitted to receive such a being. Do not suppose for a moment that all persons of the insane diathesis are geniuses or talented. Nothing could be further from the truth. Most of them are, on the contrary, very poor creatures indeed, a nuis- ance to their friends, and no good to the world at large. The insane diathesis differs essentially from the German Primare VerrucJctheit. The latter is an insanity naturally evolved in early life from the original constitution of a brain which may have been at first without peculiarity, but gradually, inevitably, and without any other cause than its own natural evolution, an unsound state of mind is de- veloped without preliminary explosion of brain-storm in the shape of an attack of mania or melancholia. LECTURE X. GENERAL PARALYSIS PARALYTIC INSANITY. GENERAL PARALYSIS is not only a variety of insanity, but a true cere- bral disease, as distinct from any other disease as smallpox is from scar- latina. It is a disease of extraordinary interest physiologically, patho- logically, and psychologically. Its study has somatized and definitized the study of all mental diseases, and has added, and will add still more, to our knowledge of the connection of mind with body, and of mental and motor disturbances. What we knew of its symptoms and pathology ought to have led to the conclusion that the cerebral convolutions have motor functions long before Hughlings Jackson, Hitzig, and Ferrier ar- rived at their generalizations on the subject. Being a distinct disease, clinically and pathologically, it can be defined, and I should give its defi- nition thus : A disease of the cortical part of the brain, characterized by progression, by the combined presence of mental and motor symptoms, the former always including mental enfeeblement and mental facility, and often delusions of grandeur and ideas of morbid expansion or self- satisfaction ; the motor deficiencies always including a peculiar defective articulation of words, and always passing through the stages of fibrillar convulsion, incoordination, paresis, and paralysis ; the diseased process spreading to the whole of the nerve tissues in the body ; being as yet in- curable, and fatal in a few years. The disease, for convenience sake, has been divided into three stages, the first of which is that of fibrillar tremblings and slight incoordination of the muscles of speech and facial expression, and of mental exaltation with excitement ; the second that of muscular incoordination and paresis with mental enfeeblement ; and the third that of advanced paresis, or no power of progression, almost inarticulate speech, and at last paralysis with mental extinction. Those stages form a convenient basis for the study of the disease. Let us look at a case in the first stage of the disease. F. Y., a fine, strong, handsome man of thirty-five, without any known hereditary predisposition to insanity, who had enjoyed good health up to the time of his present attack. His temperament is sanguine, diathesis neuro-arthritic, and his disposition frank, unsuspicious, boastful, and hasty. He always had a high opinion of himself, and showed it ; was of an imaginative turn, and had a physiological tendency to exaggera- tion. His feeling of Men etre was always above the average; his habits had been industrious, and at times he had worked very hard indeed. He had not been dissipated in the worse sense, but he had lived freely, taking lots of alcoholic stimulants habitually, eating much, sleeping generally too little, and, above all, exceeding greatly in regard to sexual intercourse, GENERAL PARALYSIS. 261 both before. his marriage and since he had been married for three years. He had never had syphilis that I could make out, and certainly has no evidence of the disease on his body. For a few months his friends have noticed that he "has not been the same." Six months ago he was "not in good spirits." and complained of flying pains in the head: then he was a little forgetful, wanting in application to his work, restless, doing some "unaccountable things" in business, e. g., forgetting to claim money due to him. He was irritable at home, a thing unusual with him. A month ago he began to express an exaggerated sense of well-being, saying he never was so well in his life, that his strength was "something wonderful: " he could not settle down to his daily work, his natural high opinion of himself was more openly expressed to comparative strangers, one of whom remarked after seeing him, " what a conceited fool that man is." This state went on without any other absolute signs of insanity, and without awakening the suspicions of his friends that he was mentally wrong that is always about the last thing thought of until one morning lie announced to his wife that he had the day before purchased several hundred pounds' worth of silver plate, and had ordered his coat of arms, with his name in full to be engraved on each article. He added that he had lots of money, and had a scheme through which in a week he would be worth many hundreds of thousands of pounds. On inquiry it was found that he had ordered the plate ; but the jeweller, being a man of sense and principle, having noticed some little thing in his manner that savored of morbidness, had not taken any steps to execute the order till he made some inquiries. Many commencing general paralytics are not so lucky as this. I knew one who spent 1000 that had taken him ten years to make in a Aveek before his disease was discovered, and another who spent .7000 in a month. F. Y.'s wife found that he had been buying a quantity of perfectly useless things in addition to the plate, some of them in duplicate. He had in his pocket four gold pencil-cases, which he said he was to give away as presents to people to whom he was under no obligation, and did not know very well. She of course saw that something was wrong, and he was got off to the country. The restlessness by night and day increased; there was constant talking, almost complete sleeplessness ; the boastfulness became in three or four days exaggerated delusions. He said he could lift one thousand pounds, that he was the best rider, swimmer, and jumper in the world ; he wanted to buy every farmer's horse he met on the road, never offering less than 100 for any animal, and at once bidding another 100 if the first offer was jocularly refused. He wrote quantities of letters to all his friends, to all the noblemen in the district, and to the Queen, offering his services to make their fortunes, and asking them to dinner. The only visible peculiarity of the writing was the omission of many single words. In a few days more he was maniacal, and so impatient of contradiction that he struck his wife, though through all this he was in many respects facile and easily managed. He therefore had to be brought to the asylum a week ago. When he saw me he offered to buy the institution for 100,000, and, on my saying that was too little, offered 200,000, and soon got up to 1.000,000. On my saying that we could not want it, he said he would build another, the most magnificent in the world, and 262 GENERAL PARALYSIS. endow it with a million a year, and appoint me physician-in-chief with a salary of X10,000, first getting the Queen to create me a baronet and giving me a splendid uniform, chiefly made of gold cloth. He has been sleepless, destructive to his clothing, not cleanly in his habits or modes of eating, in constant motion, facile in most respects, but irritable and impulsively violent when his commands were not instantly obeyed, or when he was prevented from carrying out his grand schemes. He expressed no surprise at being brought here at all, and no resentment at those who brought him. Look at him now. He came into the room with a quick step. His attitudes and gestures follow and accentuate his speech. He talks rather quickly, and has the least slurring towards the end of long sentences and in articulating long and difficult words with many oft-repeated consonants. "Round about the rugged rock the ragged rascal ran" was got through fairly well the first time, but at the second attempt the "ragged rascal" got into a sort of inarticulate slur. This is accompanied by fibrillar twitching in the small muscles of the lips and round the eyes, as if a sudden electric current had set these quivering. As he breaks into a smile this is very apt to happen. His tongue quivers in lines on its surface, single strands of muscle being affected. His pupils are contracted, irregular in outline, and the right is distinctly larger than the left, the latter being quite insensitive to light. Sometimes it is one pupil and sometimes the other that is small and insensitive, or large and insensitive, in different cases. The expression of his eyes is feverish and strange. His skin is moist, and feels hot. His temperature is 99.6, this rising to over 100 at night; his pulse is full and hard. He cannot rest or sit still. There is clearly an abnormal generation of energy in his motor batteries. When we test his common sensation, it is found to be markedly dimin- ished. His sense of smell is weakened, though it is not, as Voisin says, so blunted that he cannot smell pepper. I have seen only a few cases where smell was so anaesthetic as this. He tastes, though a little imper- fectly ; by and by he will not be able to distinguish a solution of quinine from milk. Shown a lot of colored wools, he could not tell the blue, calling it red. His patellar tendon reflex is very acute, and also the spinal and skin reflexes. You noticed how easily he was led off from one subject to another ; this facility is one of the most characteristic of all the symptoms present in all stages of the disease. But he is irritable on contradiction, and resents thwarting, especially if it is done suddenly and imperiously. General paralytics at this stage are some- times most dangerous from their absolute fearlessness of consequences. This insane boldness gives much trouble. An ordinary insane patient, if not deliriously maniacal, will usually yield to the show of force, but a general paralytic will try to fight and resist any number of men. When we try him to walk along a board of the floor, he does so sprightly and well, but on telling him suddenly to turn round, he cannot do so sharply, but takes a circle, and that waveringly. This man is in the first stage of his disease. He will steadily grow worse, losing body-weight rapidly, his speech getting worse, more tremu- lous, and having more difficulty in articulating long words and sentences. His motor excitement will be shown probably by his tearing dozens of GENERAL PARALYSIS. 263 suits of clothes all to ribbons. I have a gentleman who tore one great- coat into over a hundred pieces, saying "I'm g-g-going to put it tog-g-ger again as soon as I g-g-get to Jeru-sh-lem. I've got a million coats there." His walking will become affected, and his mental power will become gradually more enfeebled. He will believe all the delusions of his fellow-patients. A general paralytic is about the only insane person, except a congenital imbecile, who cannot see that some of his fellow-patients in an asylum are insane. Their letters are usually characteristic. Here is one : "The . . . l of the Millenium. R. E. A. When I reach the elect, teleght. office will send a despatch the Times Millenum begins. Yours in the Holy love of God and the Holy Trinity, Israel Jesu Christ." Here is another, addressed "Countess of Elgin and Durham," but really to the Queen : " HOUSE, EOYAL NATIONAL LUNATIC ASYLUM. " MY DEAR WIFE, I am very glad to say that I am up to the mark in every particular, and hope your system is up to the scratch. Has John Brown undergone any form of cremation ? I am glad to ... him adopting my style of shepherd checked trousers. I hope both Queens are well, with Princess Louise, Princess Beatrice . . . that I will give them all that is necessary in this world and the world to come. Compts. to darling ' Eugene ' Your aftct. husband." The nisus generativus is usually not exalted in general paralytics. In fact, impotence is the rule during the latter end of the first stage, and even after. I have, however, known cases where children were pro- created in the beginning of the first stage, and I have one case now who was impotent for over a year in the first stage, but whose sexual power returned in the second stage, with many other apparent signs of improve- ment, and his wife had a child to him, begotten then. He again became impotent in the end of the second stage. I have known more than one case of general paralysis who was a masturbator during the early part of the first stage. Let us now see a typical case in the second stage of the disease. F. X., now forty-five, a clerk, with a history somewhat resembling F. Y. He became affected a year ago, and has passed through a first stage of exaltation and excitement, which for the past two months has been slowly passing off. Mark his facial expression, or, I should rather say, his want of facial expression. His face looks fat, heavy, and dull, as if the expression had been wiped out of it, and this even when he speaks. There are no movements of the features corresponding with the emotions he is experiencing. There is a heavy flabbiness about him. After losing over two stones in the first stage of the disease, he has now made it up again in fat if not in muscle. There is a contented facile hebetude of mind in him. He expresses few wants, says he is quite well, and that he can walk, work, sing, or do business as well as he ever did, none of which is true, for he is very shaky on his legs, cannot walk a mile, his handwriting is tremulous, and he has no initiative mental power, no spontaneity, and no power of voli- 1 Where words are omitted. 264 GENERAL PARALYSIS. tion. He does not now obtrude his delusions, but when asked he still says in a silly way he is rich and strong, but hesitates to specify the millions he is worth, until pressed. He agrees with all you say, and is facile and easily managed. His pupils are widely dilated, and the left more so than the right ; his pulse is 68, and easily compressible ; his temperature 97, but still a little higher at night ; his tendon reflex is dull ; his spinal reflex function dull too ; his power of swallowing a little impaired. His speech is most markedly affected now, and the tone of his voice is quite changed. He cannot say " round about the rugged rock the ragged rascal ran " at all. There are still some tremblings about his face as he speaks, but they consist of the incoordination of whole groups of facial and articulatory muscles. He is very kleptoma- niacal, picking up and stuffing into his pockets any bit of trash he can lay hands on. The dorsum of his tongue presents a general undulatory surface when put out. He cannot turn round quickly without risk of falling ; he straddles a little in walking, is apt to stumble over small obstacles, and the effort of a long walk so exhausts the energizing power of his motor batteries that he gets almost paralyzed, and is then unable to walk at all. There is no vigor in any muscular movement he per- forms. His urine often dribbles away. Occasionally he is noisy at night in an automatic, causeless way. He will become weaker steadily. His speech will soon become less articulate, until he reaches the third stage, which this next patient has reached. F. W., set. 40. Has had general paralysis for two years, and has passed through the first and second stages. He is now so paralyzed that he cannot walk or even stand steadily. He cannot write, and his mental state is that of a happy lethargy. When asked if he has *a million of money his facial muscles begin to act in an incoordinated way, his eye- lids half shutting, his mouth being drawn out, the lips moving spasmodi- cally like a patient going into an epileptic fit, the whole effect being that of a contorted imitation of a smile, accompanied by a slow, prolonged, and jerky "Y-a-a-a" which is all that he can articulate for "Yes." But he looks as if his subjective condition was one of perfect happiness. He asks for nothing, he complains of nothing ; he is noisy at night often, but it is in an automatic w r ay. He needs to sleep on a mattress on the floor in a room specially warmed by hot air, for he rolls about the room at night. He is quite unable to retain his urine and feces by night or day. All his food has to be liquid or minced, for he would bolt it in solid masses and choke. He is greedy for his food when it is put into his mouth, though he is unable to feed himself. This man had two "conges- tive attacks" to which most general paralytics are subject. One occurred about the end of the first stage of the disease, and was accom- panied by unconsciousness, a temperature of 103, general convulsions which began and ended on the right side, but affected the whole body in the middle of the attack. They lasted for about four hours, and were succeeded by stupor, which lasted for forty-eight hours. He had reten- tion of urine during that time, as he slowly recovered consciousness ; after that it was found that his speech and his walking were more paretic, and his mental power more enfeebled. Congestive attacks always leave the patients worse in these respects. The second attack was of the same GENERAL PARALYSIS. 265 character, but less severe, and occurred in the second stage. Soon after it a fellow-patient struck him on the side of the head, and the ear of that side began to swell in the centre of the helix, this swelling slowly increasing in size until the ear was painted with blistering fluid, as rec- ommended by Dr. Hearder, when it ceased to increase in size, and slowly shrank up, leaving that part of the ear hard and slightly shrivelled. If it had not been blistered, the swelling would have increased until the whole ear would have looked like a bluish egg attached to the side of the head. This would have been found to consist of a bloody gelatinous material if it had been opened (but this should not be done), separating the outside skin of the ear from the cartilage. In time it would have shrunk up, leaving the outside ear a hard, shrivelled, cartilaginous-looking, ill-shapen mass. This is the " insane ear," or hcematoma auris, which is very common in general paralysis, and is sometimes seen in bad cases of mania of the chronic variety, sometimes in chronic epileptics, and occa- sionally in agitated and convulsive melancholia, and rarely in dementia. Its occurrence is always a bad sign for prognosis in any case of insanity. I have seen only three cases recover out of over eighty cases who had hcematoma auris. It is connected with arterial degeneration in the branches of the carotid artery. The gelatinous bloody contents of a hsematoma are like the extravasations under the dura mater in pacJiyme- ningitis licemorrhagica internet, a disease that is liable to occur in precisely the same class of cases. Hcematoma auris has been found in persons sane in mind, though very rarely. The exciting cause is often severe violence to the ear, but this is not necessary, and no violence will cause such a condition of the ear where the morbid arterial conditions for its formation do not exist. Blistering, if applied in time, usually stops further growth, but I have met with cases where it began to grow after being stopped, was again blistered, again ceased to grow, then again enlarged, and finally swelled up to the size of an egg in spite of blistering. F. W's. common sensibility is much impaired, so that you can stick pins into him without his feeling it. The reflex action of his cord is over-acute, and extends upwards from the section of cord irritated, for if you tickle one foot they are both drawn up with a jerk, and the two hands and the chest muscles are contracted likewise. The impression travels upwards more readily than downwards. He will soon become so paralyzed that voluntary motion in the legs of any kind will cease. He will have to be placed on a water mattress, and his trophic power will become so affected that his urine will irritate his skin and bed-sores will tend to form, and he will die of exhaustion probably within six months from this time, or within three years from the beginning of his disease. VARIATIONS FROM THE TYPICAL FORM. The usual course of this disease is well illustrated by these three patients, but a large number of the cases do not follow the typical course. For the diagnosis of those exceptional cases we require first to know clinically the varieties that are found, to understand and take into account the true pathological nature of the disease, and to be able to separate the essential from the non- essential features of it. I shall instance a few varieties of the disease. The chief of these is where the pathological process does not begin in 266 GENERAL PARALYSIS. the cortex of the brain, but in the cord (the tabic form) or in the neurine portions of the organs of special sense (the sensory form), or in a peripheral nerve (the peripheral form), spreading upwards by a patho- logical propagation along the connecting nerves in the lines of physiological function, till it reaches the brain cortex. These varieties are rare, but distinct enough when they occur, and very interesting. They would seem to imply that the pathological process of general paralysis is essen- tially the same as the progressive Wallerian atrophy of the nerve trunks, or the degeneration of the posterior columns of the cord in locomotor ataxia. I am not quite prepared to accept this conclusion, for there are as yet many pathological differences between the appearances of both of these and the brain cortex as affected by general paralysis. The essen- tial structure and the functions of the brain cortex are so different from any other portion of the nervous system that it is quite possible to suppose a diseased process of one pathological nature slowly advancing along a peripheral nerve or along the cord, and when it reaches the totally different and higher structure of the brain cortex, that it should assume a different nature, just as the process of gelatinous swelling of the synovial membrane of a joint when it reaches the cartilage, changes its pathological form, and becomes ulceration. And then it must be remembered that in those rare cases of what appear to be pathological propagation, there may have been the ordinary causes of general paralysis operating in regard to the cortex, and the peripheral disease may have been merely an extra cause at work. To show what I mean I shall refer to a few cases. G. A., a man of 50, who had been affected with ordinary typical locomotor ataxia for seven years, began to be maniacal and sleepless, and to have delusions of grandeur, affirming he was an earl and possessed millions of money, and that he could ride, run, and swim better than any man in the world. He used to write about fifty letters a day, ordering every sort of thing imaginable, asking the Queen, the House of Lords, and the Cabinet to dinner, etc. His speech was markedly affected by the characteristic tremble of the lips, the shuffle and thickness in the articulation of long words and sentences. He passed through the second and third stages of the disease, and died in eighteen months from the time of the beginning of the mental symptoms. There was no post- mortem examination in that case, but I have examined the brain and cord in other similar cases, and have found that the spinal disease could be traced up through the medulla and the lower ganglia into the brain cortex. I have always found in those tabic cases that the peculiar adhesion of the pia mater to the convolutions (see Plate I., Frontispiece) was more marked at the base of the brain and in the cerebellum instead of over the vertex, as in the typical case of general paralysis. In one such case, who died at Morningside Asylum, my late assistant, Dr. J. J. Brown, found the cord degenerated, not only in its posterior columns, but most markedly also in the anterior columns. In that case the medulla oblongata was more diseased than I ever saw in any other case of any kind. Not a single nerve fibre or cell seemed to be normal. The next case is the most typical of six cases I have met with, where- GENERAL PARALYSIS. 267 there was first disease of the retina, and then, after some years, general paralysis. G. B., having exposed his head to a hot sun while bathing, had hemorrhage into the retina, causing complete blindness. After a few years he fell into general paralysis, and Avhen he died I found that the optic nerves were hard gray cords, with no nerve substance left, that the optic tracts were in the same condition, and the gray sclerotic degenera- tion could be traced backwards to the corpora quadrigemina, the pos- terior of which were gray and sclerotic. The evidences of cortical disease were strongest at the base of the brain, the convolutions of the anterior lobes over the orbital plates being especially affected, the pia mater being universally adherent there. I knew a gentleman who became stone deaf in one ear several years before he developed general paralysis, and though I had no pathological proof that the case was one of propagation, I had no doubt in my own mind on the subject. He was a medical man, and his deafness was of a peculiar character, so that it alarmed him very much ; and when the first symptoms of general brain disease appeared, he said he thought it was just the extension of the disease from his internal ear. Professor Laycock used to quote a case of his where the disease had spread upwards from a Wallerian atrophy of one of the motor nerves of one of the fingers. I had a case, G. D., a woman of thirty-six, who passed gradu- ally into an attack of quiet, non-delusional general paralysis after a small punctured wound in the top of her head penetrating for about half an inch into the brain. A pitchfork had fallen accidentally on the top of her head, as she was loading a cart of wheat. After death the whole of the convolutions round the wound were found specially affected, though the cortex in most parts of the vertex and sides of the brain were affected as well. There are many cases of general paralysis where the course, and even the nature, of the symptoms vary, within limits, very much from the typical symptoms and the typical course. They constitute' symptomato- logical varieties of the disease. The most common and the most marked of these is the non-delusional variety, as seen in the following case, where there was no excitement, no delusions of grandeur, and no conges- tive attacks, but simply a gradual mental enfeeblement beginning with the volitional power, and a gradual paresis beginning with muscular weakness and fibrillar tremblings in the facial muscles and tongue, this gradually passing into complete incoordination. 0. C., aet. 50. A quiet-living man, who had married about three years before he became affected in mind, first showed mental defect by irresolution, want of a keen interest in anything, forgetfulness, and the want of a realizing sense of the necessity of his working in order to live. Soon he got a little irritable when pressed to work. Then his mind showed clears signs of enfeeblement and facility. He would believe silly things, he could not carry on a connected conversation, he had few likes or dislikes. I saw him at this stage, and found his speech thick, his lips showing, as he began to speak, that fatal quiver which to a practised eye almost marks the disease from all others. His walk, too, was not firm, and in turning round sharply he did so uncertainly. He 268 GENERAL PARALYSIS. gradually got more enfeebled and frail in mind, his speech became less articulate, and his walk more paretic. Nearly all his symptoms were negative. About the only positive mental symptom he had was a gentle kleptomania. He would pick up and fill his pockets with stray pocket- handkerchiefs, aprons, and rags in a sort of automatic Avay, not in the least caring or objecting Avhen they were taken from him. He died in six years, absolutely paralyzed, of pure exhaustion, never having made a sound that could be called articulate for a year, or voluntarily moved a voluntary muscle during that time, lying on a water-bed, and leading a merely vegetative life. Such cases are apt to live a long time. They are not usually caused by a dissipated or excited life, and their subjects were originally of a calm, phlegmatic temperament. Nearly one- third of all the cases of the disease that I have seen were of this character. This type is very common in the female sex ; in fact, the majority of female cases conform to it more or less. It is also the common type of the disease in those parts of the country where the people live unex- citing lives. Standing at the opposite point from this quiet form of the disease are the two varieties of which I shall now give examples. The first is the specially convulsive form, as exhibited in the following three cases: G. E., set. about 40. A man who had been of an excitable disposi- tion, and had led a dissipated life in regard to drink and women, of a fiery temper; who had suffered from syphilis, whose whole life had been a whirl of mental excitement. He had complained for some time of very severe headaches, had been off his sleep, had been unusually irritable and not fit to do a day's business. One day he suddenly fell down in a fit, and remained in general and severe convulsions with complete stupor for about two hours and died in them. After death, I found all the patho- logical signs of general paralysis; especially the adherence of the pia mater to the convolutions of the vertex in patches was most marked. There was no local disease in the membranes or vessels that has been recognized as syphilitic, and he had not been drinking heavily before his death. My conclusion was that it was a case of general paralysis, with a strongly convulsive tendency, this killing the patient before the usual symptoms had time to develop. I do not know whether I should or not have been able to diagnose the case had I seen him before the convulsive attack, or whether there were any motor symptoms present before it occurred. But, it may be said Is it possible for a man to have marked disease of the brain affecting the convolutions of the vertex, without mental or motor symptoms? My experience of general paralysis would lead me to the conclusion that the recognizable pathological lesions of the convolutions precede the mental symptoms. They usually need to develop in some intensity, and to involve a certain number or kind of convolutions, before mental or motor symptoms become very manifest. I had a general paralytic in the asylum, G. A., who took an epilepti- form convulsion every day for months. The temperature rises often before, and always after, an epileptiform convulsion or a mere congestive attack in these cases. I had another patient who had many epileptic- looking fits for a year, and who was treated for epilepsy by eminent physi- GENERAL PARALYSIS. 269 cians during that time, before the usual mental and motor signs of general paralysis appeared. The next marked departure from the normal type of general paralysis, such as I have described it, is where the first stage consists of maniacal exaltation alone, without any motor sign that one can recognize, for months, and even years. I have had several cases now who had what appeared to be attacks of ordinary acute mania, and to all appearance had recovered, who had even second attacks and recovered, and then developed the motor symptoms of general paralysis. The following is one of them : G. G., get. 36, an Irishman born (Irishmen often enough suffer from general paralysis here if they do not at home), drunken and hard work- ing; married. Had an attack of "acute mania" in 1876, and was sent to the asylum, and "recovered" in five weeks. No motor signs or evidences of general paralysis were noted by me or anyone else here. In 1878, he had another attack, and this time some suspicion of the disease was excited, but no diagnosis made. He was again discharged recovered, and it was only on his third admission, three years after his first, that the disease was manifest. He died of it in three years. I lately saw a case with Dr. Bramwell, in which I had no doubt whatever as to the nature of the disease, and have none now, in which the symptoms were those of the second stage, with indistinct articulation, difficult walking, great mental facility, epileptiform convulsions, and bed-sores, and yet he has so far improved that he has gone to work as a draughtsman, and is said to be doing his work well. In such a case as that of G. G., I have no doubt whatever that the first attack in 1876 was really a part of the general paralysis, but at that time the disease was probably superficial in the cortex and confined to a limited area, and did not involve to any extent the motor centres in the convulsions, causing, no doubt, much congestion and much vesicular overactivity in the cortex, but not incoordination of motion. The first attacks were brain storms that passed away, so far as the active congestion and the vascular disturbance were concerned, leaving the incipient organic convolutional change there, but quiescent. I have also no doubt in fact, I obtained clear evidences of it from his wife that intellectually he was weakened after the first attack of "acute mania" in 1876. Such cases enable one to understand the "recoveries" and "cures" of general paral- ysis, not one of which, I believe, was ever real or lasting. It is common to have in the beginning of the first stage very acutely maniacal mental symptoms, and no motor signs to be discovered, and general paralysis should never be diagnosed from mental symptoms alone. I had a case, G. H., who was most acutely maniacal, very dangerous, very homicidal, very impulsive, and very strong willed and unmanageable for twelve months before there were any motor symptoms that enabled me to diagnose general paralysis. From the state of his pupils, and the looks and expression of his face, I suspected it, but I could not have said definitely it was any other condition than acute mania for the first twelve months. It is very uncommon for a man who suffers from general paralysis to have been insane before, but I have met with a few examples. One, G. H. A., had an attack of mania in youth, recovered, kept well, 270 GENERAL PARALYSIS. and did his ordinary business for twenty years, and at the age of forty- four became a general paralytic. We have certain long-lived cases that do not die at the normal time, but live on for periods up to twenty-two years. I have now under my care such a patient. G. J., set. 35, admitted to the Royal Edinburgh Asylum 18th Novem- ber, 1860. Had led a somewhat rough life, and nine months before had an "epileptic fit." No heredity to insanity, but he had a very eccentric, somewhat silly sister. The attack had been preceded by a melancholic condition, and he had refused his food. His articulation was slurred, his pupils unequal, his walk slow and unsteady. He was unhesitatingly diagnosed as a general paralytic. After nine months he was taken out of the asylum by his relatives, but had to be sent back again in eighteen months, having been, while outside, totally unable to do anything for his own livelihood, and having got gradually worse in mind and body. When admitted in 1863, he was "stout, stupid, and silent," had the "peculiar expression of face of general paralysis well marked, as well as its walk." Some days he was "quite well and happy." In a few months, he was "uproariously happy," with the most exaggerated notions about his riches, strength, height, beauty, etc. He is forty feet high, is God, is married to the Queen, is the strongest man in the world, and has a "damnable heap of money." All Leith Docks belonged to him, and most of the ships there. In December, 1863, he had a series of epilepti- form fits, which were ushered in by a regular congestive attack. He became very weak, and could with difficulty articulate, or make his water. He got over this condition in a few weeks, and became facile and con- tented. An assistant physician of the asylum recorded in the Case-book in 1864 "Is a magnificent specimen of a general paralytic." In June, 1864, he had a congestive attack, succeeded by epileptiform fits, being maniacal and restless afterwards. In August, 1864, he had another congestive attack, and one in January, 1865, and got so frail in March that he had to be kept in bed. In March he had another congestive attack. He had no congestive or epileptiform attack again till December, 1880. During all these years the symptoms remained the same, but the disease did not advance much till after the epileptiform attack in 1880. The period of general convulsion was short, only a few minutes, but he was confused and stupid afterwards for four hours, and was then excited and noisy. The paresis increased after this, and the general strength failed much. In February, 1881, he had another severe attack of gen- eral convulsions, with several hours of stupor following them, the tem- perature rising to 102.4 in three hours, and then falling to normal in two hours after that. He had two such attacks in April of that year. After the last the left side was found weaker than the right, and he was shaken generally. During the summer he could not walk far without becoming paralyzed in his legs ; he had incontinence of urine, his speech was thicker and less articulate, and mentally he was more facile and stupid. At present (November, 1882) twenty-three years after the commence- ment of his illness, his condition is as follows : Facial expression vacant ; pupils both contracted, but partly sensitive to light, the left being slightly GENERAL PARALYSIS. 271 the larger, outlines not regularly circular ; tongue tremulous, and its muscles incoordinated over surface; articulation affected just like that of a typical general paralytic at the end of the second stage of the disease, difficult words being worst pronounced, and the ends of sentences worse than their beginning; walk uncertain, dragging, straddling; sensibility diminished, can smell pepper, but cannot be made to sneeze ; spinal reflexes very acute, patellar tendon reflex quite absent. Often has retention of urine. Begins a walk pretty well, but soon fails, and cannot progress at all ; turns round with difficulty ; cannot stand on one leg ; whole nutrition flabby ; mentally in a facile, morbidly contented, exalted state. It may be said that, as he has not died, it is impossible to say that this is a case of true general paralysis. If he is not, he has had every symptom of the disease except its termination in death, and neither Dr. Skae nor I, nor one of the score of assistant physicians here who have had charge of him, has had any doubt on the subject. The common age for the occurrence of the disease is between twenty- five and fifty. The chart in Plate VI. shows its prevalence in one hundred and four cases admitted to this asylum as compared with mania and melancholia, and the ages at which it occurred. The greatest number of cases occurred between forty and forty-five years. But there are a few exceptional patients. We have had at Morningside two cases under twenty, one at sixteen, and the other at twelve, accounts of both of which were published, one by Dr. Turnbull, and one by myself. The diagnosis in both being confirmed by a post-mortem examination, there could be no doubt as to the nature of the disease. Instead of the exalted condition of mind, or the merely enfeebled and facile one, we have a few cases (from three to four per cent, in my expe- rience) with melancholic symptoms. My belief and experience is that in all these there is some organic visceral disease which transmits to the con- volutions sensations that are disagreeable and depressing. On examina- tion of our pathological register, I found that nearly all the cases of the disease that had tubercular disease or broncho-pneumonia had been melancholic. I had a man, G, K., who had the fixed melancholic delusion that a man was inside him who annoyed him constantly, and made him really depressed, and after death we found tubercular disease of the intestines. I have a most instructive case now showing the influence of visceral disease on the mental condition of a general paralytic, G. L., a cabman, who thought on admission he had ,30,000, and got X1000 from Queen Victoria for driving her along Princes Street. Suddenly one day he became melancholic, saying he was a beggar, and crying bitterly. We examined his chest and found he had bronchitis. The reflex action was so dulled, as in most cases of the disease, that he had no cough, felt no pain, and made no complaint. As his bronchitis improved, his mental elevation and delusions of grandeur returned. He had a relapse, and the melancholic state at once came back. For a week or so he was elevated one day and depressed the next. At last the bronchitis was recovered from, and he is the happy imaginary possessor of his thousands. Whenever I see a general paralytic dull now, I always search for an organic visceral cause, and usually find it. I had one case of the disease, G. M., that began with aphasia, and was 272 GENERAL PARALYSIS. treated for several months for this. As he began to speak, the peculiar articulation was noticed, and he died in about two years. In his case, the motor reflex excitability of the brain and cord was greater than I ever saw in any case whatever. A very slight tap on the toe would set up a convulsion first in that leg, and then in the next ; a slight puff suddenly into his face would make him jump off his seat with his whole body. I have many times seen general paralytics aphasic after conges- tive attacks. In such cases, and in all cases where the speech was specially affected during the disease, I have always found after death that the third frontal convolution of the left side and that region of the brain had the pia mater especially adherent to the cortex. I have only seen one patient in which long-continued ordinary insanity became changed into general paralysis. It was a case of dementia of twelve years' standing. It was an exception that proves the rule that general paralysis and ordinary insanity have nothing in common patho- logically. The conditions that are most apt to be mistaken for general paralysis are alcoholism, syphilitic insanity, paralytic insanity, certain cases of epileptic insanity, acute mania with ambitious delusions, choreic insanity, some senile conditions, some traumatic cases, and some imbeciles with stuttering speech. PATHOLOGICAL APPEARANCES IN THE BRAIN IN GENERAL PARALYSIS. At this point I think it is better to complete the clinical history of the disease by describing very shortly the pathological appearances met with in the brain. The encasings and supports of the organ are all found to be affected, and the longer the case has lasted the more marked are the changes met with. The bone of the calvarium is denser and harder, in many cases the diploe being obliterated, and in many others there is a distinct layering and deposit of new bone on the inside of the inner table of the skull-cap, this being usually confined to the frontal and parietal bones. The dura mater is thickened, adheres more or less mor- bidly, and frequently leaves shreds attached to the bone. In many cases I have seen spicula of bone growing in it at the junction of the falx, which is always much thickened. When the dura mater, often in layers, is reflected, the most characteristic morbid appearances of the disease are seen. I have endeavored to depict some of them in Plate I. (see Frontis- piece). In a number of cases we find, under the dura mater, and attached to it, lying between it and the arachnoid, a new substance of a morbid and peculiar kind, commonly called a false membrane. It varies in consist- ence from the fibrous texture of the dura mater itself to a fibreless jelly, in color from a grayish-white to that of a blood-clot, in thickness from a film to a quarter of an inch, in extent from a small patch or two to- a covering of both hemispheres above and below. It is usually thickest over the vertex. In some cases it looks like a clot, in others like an extra layer of dura mater, but it can always be easily scraped away. When it is removed from the dura mater that membrane is not congested or inflamed looking. It always contains new bloodvessels, and nearly always blood-corpuscles or blood-coloring matter. On microscopic examination it is found to consist of a newly organized fibrous tissue, in GENERAL PARALYSIS. 273 a gelatinous matrix with much granular matter, white and red blood- corpuscles, and newly formed and forming capillaries with tender walls. This is the so-called pachymeningitis hcemorrhagica internet of the Germans, a ridiculous and misleading name, for it is not the result of inflammation at all. The formation of the substance is, to my mind, full of interest and instructiveness. It implies a very great intensity of morbid action in the convolutions, and probably also great and sudden changes in the blood pressure within the cranium. Under the membrane if present, and under the dura mater if not present, we see in all well-marked advanced cases the appearance presented in Plate I. on the anterior lobe. The arachnoid is immensely thickened, and either mottled with white spots or striated along the sulci with white fibrous-looking bands. Under it there is what looks like a dull opaque jelly, through which the convolutions dimly appear, and under which great tortuous congested veins meander; some of these being perhaps, if the case has died during or after a congestive attack, obstructed by little white masses of hard ante-mortem clot. But this is not really a jelly, for if the arachnoid is pricked it nearly all oozes out as a dirty opaque fluid, which varies from two to six ounces in quantity. This is a really compensatory fluid, filling up the space left vacant by the atrophy of the convolutions and brain generally. It does not nearly represent the whole of the brain atrophy, for we have, in addition, enlarged ventricles and dilated perivascular spaces, Avhich often contain six ounces more of fluid. After the fluid has drained off, the pia mater and the convolutions are better seen. Both are strikingly abnormal. The pia mater is thickened, vascular, and tough to an enormous extent. The convolutions are atrophied, especially over the vertex of the anterior and middle lobes and in some localized places elsewhere, and generally tend to be wedge-shaped, and to lie loosely together. When the pia mater is removed from the convolutions (do this in every case of mental disease you examine), it is found to adhere to and raise up portions of the outer layer of the gray substance on the ridges of the convolutions (seldom in the sulci) which stick to the pia mater, are removed with it, and appear as irregular patches over the membrane that has been detached from the brain (see lower part of Plate I.). The convolutions from which those patches have been removed look eroded like the surface of a cheese where a mouse has been (see middle portion of Plate). Now, this adhesion of the pia mater to the convolutions is a very morbid phenomenon. It has never been found to any extent in any patient whose mind was sound and strong before death. It is, in different cases, confined to a few convolutions, or is general over all the brain. It is by far most frequently confined to the vertex and to the anterior and middle lobes, and to the gyri round the olfactory bulbs at the base. The two hemispheres usually adhere anteriorly, and in the attempt to separate them some of the substance of the convolutions will be torn away. In some cases we find this adhesion of the pia mater at the base, over the orbital convolutions and the middle lobes. I have never seen the tips of the posterior lobes much affected. They are usually healthy looking. Though the adhesion is only partial in most cases, I have seen it almost universal. It merely represents, in my opinion, the acme of a pathological 18 274 GENERAL PARALYSIS. process that is very general in the convolutions. In examining the different convolutions of the brain of a general paralytic microscopically, and the different parts of one convolution, we find that, though the morbid appearances are in greater intensity in one place than another, they by no means coincide in absolute intensity with the parts to which the pia mater has adhered. I have found as much disease microscopically in a convolution to which it did not adhere as in those to which it did. There is rarely or ever much adherence of the pia mater that dips down into the sulci, and I have never seen one convolution adhering to the next. This fact alone has always settled the question, in my judgment, that the disease is not of inflammatory origin, using that word in its ordinary sense. The fact is, that the pia mater which dips in and separates adjoining convolutions is different in composition and use from that portion which overlays the whole brain. The former contains no lymphatics, and is a mere fine network of fibres to hold the vessels, while the latter is full of lymphatic spaces. On section the gray matter of the convolutions affected is usually divided into two distinct layers, the outer being gray and opaque looking, and there is often a line of red congestion as the demarcation between those two. Along this line the brain tissue seems softer and more pultaceous. There is no real sclerosis, though, on the whole, the outer layer of the gray substance may be slightly harder in texture than normal. In some cases, however, it is distinctly softer. The whole gray matter is thinner, especially in the cases that have lasted long. The white substance is often very congested, especially in irregular patches (as seen in Plate III.), its perivascular spaces are always enlarged, and the small tessels tough and their coats thickened. On opening into the ventricles they are nearly always found enlarged, but the most striking peculiarity is, that their normally delicate epithelial linings are toughened and roughened in an extraordinary degree. Their surfaces look in the less marked cases like frosted glass, in the more marked cases they are granular, and even minutely nodular, feeling rough to the touch. They are leathery, too, when torn. This condition is usually most marked in the floor of the fourth ventricle, and the cover- ing of the calamus scriptorius is always a grayish, gelatinous-looking, but really tough membrane. The microscopic examination of a section of such a granulation at once shows what has taken place (see Plate VII., Fig. 3). The single normal layer of delicate epithelium has become enormously hypertrophied, and has thrown itself up into great nodular masses of epithelial cells, arranged in some cases in layers of one hundred cells deep. In the deeper layers the cells have become flattened and hardened, so that they have a fibrous appearance, and the brain substance on which they rest has undergone a process of sclerosis. Those granulations are in fact innumerable epitheliomata growing over a fibrous membrane. There is no single tissue in the brain whose condi- tion is so morbid as the epithelial linings of the ventricles. This is another proof, if any were needed, that general paralysis is not an inflamrnmation proper, for in inflammation the first thing the epithelial cells do is to fall off while it lasts. A microscopic examination of sections of the convolutions (see Plate GENERAL PARALYSIS. 275 VII., Fig. 5) shows enormous proliferation of the neuclei of the rieuroglia, which takes place most along the small vessels and capillaries. The outermost layer of the convolutions is thinned, altered in appearance and structure, and in the advanced cases converted into a dense unorganized- looking texture, instead of the beautiful and regular layer of small cells and fine granules of a healthy convolution. The larger cells further in, and the large multipolar cells, are more or less degenerated or atrophied, especially in patches and areas. The bloodvessels are diseased, their coats being thickened and full of nuclei. Sometimes they are obliterated and thready. The perivascular canals are morbidly enlarged, sacculated, and filled with all kinds of organic debris, blood coloring-matter, granules, and minute apoplexies. There can be no doubt that those canals and the spaces in the pia mater act as lymphatic ducts. Having been obstructed during life, little effete material could have been carried along them. There is no nervous tissue that is not found diseased and degenerated in advanced cases of the disease, the retina, the peripheral nerves, the sympathetic ganglia, etc. NATURE or THE DISEASE. What, then, is general paralysis ? There are few diseases whose essential nature we as yet know. But we know that the special trophic energy and inherent physiological qualities of different tissues become perverted in special ways, so that most tissues have their own special types of disease. There can be no doubt that the gray substance of the convolutions of the brain of man is the highest in quality and function of any organic product yet known in nature. That substance reaches its highest development in the male sex between adolescence and middle life. Its uses are called forth in the highest degree in the European races who live in towns. Its physiological abuses by alcoholic and other poisoning, by over-strain, by violent energizing stimulated by continuous strong mental and other stimuli up to the point of exhaustion, are also most common under those circumstances. Its outer layer or rhind is most delicately constituted, has far more blood (see Plate VII., Fig. 5) and more minute cells than any other portion of the brain, and, on the whole, may be regarded as the most important factor in mentalization, being in fact the mind tissue. Immediately underlying it in the convolutions, in certain parts of the brain, we probably have the originating motor cells. This outer rhind of gray matter, this last evolved and highest organic substance, is precisely that affected in general paralysis. The proof goes to show that this is first affected in the typical cases, and that all the other nervous degenerations which finally affect the whole nervous system are subsequent and sequen- tial. Granted a progressive and incurable disease of this mind tissue, towards which the whole of the rest of the nervous system tends and in which it ends, which controls and regulates it all, and which is its crown and highest development, it is quite explicable that all the rest of the nervous system should degenerate in structure and function, and in fact die slowly and progressively. It is a quality of nerve tissue to degen- erate in the lines of physiological activity, when that activity ceases either in a higher centre or in the part innervated. General paralysis is a disease of this outer layer of the cerebral convolutions of the mind 276 PARALYTIC INSANITY. tissue in fact. It is essentially a death of that tissue. I look on it as being equivalent to a premature and sudden senile condition, senility being the slow physiological process of ending, general paralysis the quick pathological one. The causes of it are causes that have exhausted trophic energy by over-stimulation. Its first stage is accompanied by undoubted morbid vaso-motor dilatation, so that all the tissues enveloping the brain, and holding its elements together, receive an abnormal supply of blood, and thereby acquire tissue hypertrophy the bones of the skull- cap, the membranes, the reuroglia, the epithelium, and the arteries. Just as the tissue degenerations, especially the brain degenerations of old age, cannot be arrested, and are necessarily progressive, so is general paralysis. Those high nerve cells have lost their once inherent power of self-restoration, and so they degenerate and atrophy. The diseased process is peculiar, because the tissue in which it originates is peculiar. Its motor accompaniments are really not more inexplicable than the ordinary senile speech and senile incoordination. LOCAL DISTRIBUTION. General paralysis prevails in some places and in some races, and is unknown in others. As yet the Asiatic is not subject to it, the savage is free from it, and the Irishman and Scotch Highlander needs to come to the big towns or to go to America to have the distinction of being able to acquire it. The female sex is very un- susceptible of it, but if women drink bad liquor and live riotous, excited lives, as in the cotton and manufacturing districts of England, they too will become general paralytics. I have only seen one female in the rank of a lady suffering from general paralysis. The things that most excite and at the same time most exhaust the highest brain energy are those that tend most strongly to cause the disease, viz., over and promiscuous sexual indulgence combined with hard muscular labor, a stimulating diet of highly fed flesh meat, the brain being all the while excited and poisoned by alcohol and syphilis, all these things being begun early in life and kept up steadily. In this country the Durham miner, when earning good wages, fulfils the most perfect conditions yet known for the production of general paralysis. Every sixth lunatic admitted to the Durham County Asylum is a geneal paralytic. Hard study, or severe mental shocks, or traumatic injuries, or continuous anxiety, will also produce the disease. I do not think there is any proof that it is syphilitic m origin. PARALYTIC INSANITY. Paralytic Insanity, or Organic Dementia, is that form of mental dis- turbance which accompanies and results from such gross brain lesions as apoplexies, ramollissements, tumors, atrophies, and chronic degenerations of the brain, affecting the convolutions and their functions either primarily or secondarily. It has nothing whatever to dj with general paralysis. Its symptoms vary according to the position, kind, and intensity of the pathological process. But it is typically a dementia, an enfeeblement, a lessening of the mental power, superadded to some sort of motor paralysis. Along with this enfeeblement there may be, and there usually is, a certain amount of depression at first, followed afterwards by a mild exaltation and PAKALYTIC INSANITY. 277 emotionalism of a childish kind, this gradually passing off and leaving the patient, if he lives long enough, forgetful, helpless, and torpid. Paralytic insanity, like general paralysis, has a gross and demonstrable pathological basis, but it differs widely and essentially from it in not being a specific disease of the brain convolutions, in not running a progressive course, in not being necessarily incurable, in the irregularity and variety of the mental symptoms present, and of the pathological lesions. It is best and most commonly seen in a case where there has been apoplexy from rupture of a bloodvessel in one of the great basal ganglia, or embolism, or throm- bosis, followed by local starvations of brain tissue, and ramollissement ; those destructive processes cutting off large tracts of the convolutions by destroying part of the projection and association systems of fibres by which the convolutions are brought into connection with the basal ganglia, the cerebellum, and the cord and the muscles, or with each other. This interruption may of itself sensibly affect the mental power, and those pathological processes tend to advance up into the convolutions, so de- stroying the sources of mental energy directly. A brain affected by apoplexy or embolism, and in that case probably having its bloodvessels generally diseased, is an organ on the verge of dissolution. Such pro- cesses are the beginning of the end in most cases, and the mental symp- toms are often the most prominent and by far the most troublesome. Yet, after all, they are not the essential part of the disease. This disease is not an insanity in the popular acceptation. In most cases the gradual mental decay is never thought of as a mental disease at all. It is rather looked on as a necessary and natural accompaniment of the bodily disease. In most cases it is not at all beyond the ordinary nursing capacity and management available in the patient's home, if he has any money or relatives at all. The very poor in the great towns, when affected by it, are sent to workhouses, and not usually to asylums for the insane. It is only the worst and most troublesome cases that it is necessary to send there the noisy, the restless at night, the very dirty, the troublesome. Motor restlessness is a special characteristic of the worst class of cases, and this often needs, for the protection of the patient, special nursing and special rooms. But there is no essential difference between the helpless hemiplegic whose memory is gone, his energy impaired, his thinking capacity paralyzed, and his affective power deadened, who sits in his easy-chair at home, and the restless, shouting, sleepless paralytic insane man in the hospital ward of an asylum. The heredity of the patient plays an important part in the origination of paralytic insanity of the more marked kind. While a man with no nervous heredity will have a large spot of progressive softening in one of his corpora striata, and yet will be calm, reasonable, and quite manage- able, though forgetful, torpid, and emotional, the man with a bad nervous heredity will become, under the same conditions, restless, depressed, noisy, and sleepless. There is no doubt that apoplexies and all sorts of other . gross limited lesions produce, in unstable brains, great convolutional dis- turbance through reflex excitation. If such brains are unstable in their motor centres, we have convulsions, local or general ; if there is heredi- tary mental instability, then we have the ordinary symptoms of mania or melancholia. I had once as a patient a young woman (G. N.) under 278 PARALYTIC INSANITY. thirty, who, having heart disease, became hemiplegic on her right side, and aphasic after the birth of a child. Immediately after these came on great mental depression, with suicidal tendencies, for which she had to be sent to an asylum. The hemiplegia soon passed quite away, but the aphasia remained all her life ; and when the mental depression passed off in a few months she gradually became exalted, and remained so for some months. Then she again became depressed, and was mentally a typical case of alternating insanity (folie circulaire) for the seven years she lived after this. She at last died of the heart disease, and I found Broca's con- volution almost destroyed by an old embolism, but the rest of the brain with only the traces of repeated excitations and congestions. In this case, which I mention as being a very rare and most unusual kind of paralytic insanity, the embolism and its consequences no doubt excited into pathological activity a previously existing hereditary weakness of the mental portions of the convolutions which had before that been stable in their working. In the more typical cases of paralytic insanity the same thing occurs in old and partially worn-out brains. There is a close analogy in symptoms, pathology, and course, between paralytic and senile insanity. In fact, the majority of paralytic cases are also senile. In a brain with general senile degeneration and diseased arteries, a local lesion occurs, and we have it exciting and lighting up a general convolutional flame. I have had many cases where there was a family tendency to mental disease, but it had never shown itself in any actual symptoms till the very end of life, when an attack of paralysis occurred, and this was followed by melancholic or maniacal symptoms and subsequent dementia. I have had several such patients whose children had become insane at an early age long before them, but they remained well till they became hemiplegic. One such case was G. 0., set. 67, who remained quite well mentally, and did his work till he had a slight attack of left hemiplegia. Then he became melancholic, sleepless, and suicidal, and had to be sent to the asylum, where his daughter, G. P., had been a patient for thirteen years, suffering from essential paralysis of infancy on the right side, epilepsy, and dementia. The motor symptoms in paralytic insanity must be regarded as integral parts of the disease. The speech is the most characteristic of these in the ordinary hemiplegic cases. It is a thick articulation, not a tremulous speech. Every word from the beginning of a sentence to the end is im- perfectly pronounced. There is no tendency to fail more at the end of a sentence than at the beginning. The labial and facial muscles do not quiver before or during the articulatory process, as in general paralysis, though the tongue usually trembles when put out. It is a simple paretic, not a convulsive, speech. Long, difficult words and sentences are attempted, and got through with in a way, but are not found impossible of attempt, or end in a more inarticulate prolonged vowel sound, as often in general paralysis. In the latter disease it is essentially a convolu- tional lesion speech ; in the former it is a basal motor ganglia lesion speech. In the former it is the originating motor speech coordinations in the convolutions that are aifected, in the latter the secondary coordi- nations lower down. In very many of the paralytic cases we have apoplexies and similar lesions of the convolutions themselves, and in such PARALYTIC INSANITY. 279 the speech symptoms are always more like those of general paralysis. In such patients, too, we are apt to have epileptiform, epileptic, and con- gestive attacks. In many instances, even when the original lesion has been in the corpora striata or in the motor fibres of conduction near it, destruction of tissue will go on up to the convolutions ; in fact, if the patient lives long enough it is sure to do so, and the speech will become more like that of the second stage of general paralysis. I need hardly say that if the lesion affects the posterior portion of the third frontal convolution of the left side, or the Island of Reil on that side, or the fibres of communication inwards from those parts, or certain portions of the extra-ventricular nucleus of the corpus striatum of that side in such cases we will have the aphasic speech symptoms. It is a disputed question whether complete aphasia can coexist with perfect integrity of the intellectual faculties. If the lesion be strictly limited to the speech centre, which it very rarely is, the loss of mental power may be slight, but whether we can have mental completeness according to the previous standard of perfect health of the individual is another matter. I do not believe we can have such completeness if we could apply proper tests. I have never seen a case where it existed. Here is a kind of case, very common indeed where extreme bodily helplessness coexisted with such mental symptoms as made the patient's presence almost intolerable in a private house, and even to the neighbors who lived near. G. Q., set. 64. Had an attack of apoplexy with left hemiplegia four months before it was necessary to send her to the asylum. Her mother died of apoplexy at the age of eighty -four. There was no other neurotic heredity discoverable. During the first month after the apoplexy she was stupid and half comatose. Then she began to have hallucinations of sight, and to be fanciful, irritable, and very unreasonable, to sleep badly, and to have a morbid craving for food with no sense of satiety. The mental symptoms got gradually worse, while the hemiplegia remained complete. She became subject to periodic fits of depression, lasting whole days and nights, during which she would cry and scream loudly without intermission in a peculiar baby-like voice that penetrated through the house and into the street, and was most annoying to the neighbors, especially at night. There was no reasoning with or soothing her. It was evident that she had a sense of extreme organic discomfort, and that she probably had pain. Her delusions all took their origin from her sensations. She affirmed that her left leg and arm did not belong to her, and would order that they should be taken away. She affirmed her food was poisoned, and she said the people near her were going to kill her. She could not attend to the calls of nature, and when moved to be dressed and washed screamed at the pitch of her voice. She had no memory at all for recent events, but lived in the past. She was very emotional, crying nearly every time she was spoken to, but her appear- ances of emotion, like the rest of her mental life, were merely automatic. She showed no real affection for her family. She constantly threatened suicide. She mistook the identity of those about her, calling strangers by the names of old friends. With the hand she could move she would try to tear and destroy and break things. After about three months of 280 PARALYTIC INSANITY. this state she had to be sent to the asylum, chiefly on account of the noise she made. She was fed and nursed and cared for, placed on a water-bed, and kept warm, and placed in a room where her noise did not disturb others. Sedatives and soporifics, such as the bromides and chloral, were tried in moderate doses. They usually did not act in producing quiet or sleep till twelve hours after they were given. This is a common thing in maniacal conditions. An old night attendant I once had pointed it out first to me. He divided his noisy people into two classes those in whom the night draughts produced sleep the night they were given, and those in whom they produced sleep only on the following night. Though sleep was thus produced in G. Q.'s case, it was not restful or in any way bene- ficial, while her appetite was lessened and her strength impaired. After frequent repetitions of the bromide of potassium and chloral she got quite drowsy, stupid, and would take no food at all. It seemed as if the only things to be done with benefit were nursing and feeding. The advanced and advancing brain disease being destructive and irritative in its character, evidently involving the convolutions to a serious extent, seemed capable of no alleviation. She steadily got weaker, and died in about four months from the beginning of the attack. No post-mortem examination was permitted. The case, looked at from the point of view of mental symptoms, was one of melancholia of the excited variety ; but the whole of the mental symptoms were so secondary, in a clinical point of view, to the attack of apoplexy and hemiplegia, that it is evident the appropriate name for such a case is that of paralytic insanity. The irregular periodicity in the symptoms, and the days of quiet she had. seemed to me and this is markedly the case in many senile cases too to be merely the stupor and inaction of a spent organ, that could no longer evolve morbid energy through sheer exhaustion till an accumu- lation again took place. The following is a good example of insanity from an advancing paralysis, not hemiplegic at first, caused by progressive brain destruction : G. R., set. 57. Habits intemperate. No admitted heredity to the neuroses. Four years before admission to the asylum he had some sort of attack that was described as "bilious," becoming almost blind after it. He then became subject to severe headaches. About fifteen months before admission he had a paralytic shock, affecting both sides equally, and since then his mental power has gradually become impaired. At times he was noisy and unruly in a stupid, purposeless fashion, thinking that some one was coming to hurt him. When he could not find his razor one day he set fire to his beard. He would attempt to leave the house with nothing but his night-shirt on. He slept badly, and was restless, and often noisy at night. He used to repeat his former acts in an automatic absurd way, e.g., one day was found fishing in his grate with a bit of string tied to a stick. His memory especially failed. When, on account of the excitement, noise, and difficulty of manage- ment at home, he was sent to the asylum, he was not apparently exalted or depressed or excited, but he was much enfeebled in mind, his speech and behavior being childish, and his memory almost gone. He could not tell the day of the week, or his age, or the number of his children. PARALYTIC INSANITY. 281 He expressed no delusions. His power of attention was lessened. He evinced no great surprise or curiosity at coming to the asylum. His face was expressionless and flabby, his gait dragging and weak, and his grasp feeble. His articulation was characteristic of such cases, being thick and slurred, but not tremulous. It Avas simply a muscular inability to perform the fine coordinations of speech. The tongue was furred, flabby, and tremulous on its surface. The bowels were constipated. Heart enlarged, and sounds impure. The sensibility and reflex action were normal. The urine was slightly albuminous. Temperature 98, pulse 84. After coming to the asylum, there was a steady downward course in mind and body. He was restless, and very liable to fall over any little obstacle and hurt himself. He slept badly. He was perfectly contented in mind; but if you spoke in a sympathetic tone, he would burst out crying without being able to assign any cause. At first he was able to keep himself clean, but soon his urine and then his feces passed without his paying any attention. At night he was often noisy and very restless, and he needed to have his bed-clothes put on and be attended to by the night attendant constantly. Was placed in our infirmary ward, and needed much attention by day and night. In four months he was con- fined to bed, and almost entirely paralyzed, but still noisy. Then he got in a condition of semi-stupor, and in eight months after admission had an attack of apoplexy with left hemiplegia and coma, and died in twenty- four hours thereafter. The whole disease lasted four years, during the last two of which he was partially paralyzed and affected in mind, and for the last eight months he needed asylum treatment. A post-mortem examination was not allowed. The following is an example of the kind of recovery that sometimes take place in paralytic insanity : G. S., set. 62, a steady, temperate man. His sister was a patient in the asylum once. Two years before admission he had had two shocks of paralysis on the left side. Since then he has got more and more "nervous," and at times noisy and violent. For six weeks before ad- mission he had been distinctly insane. He was poor, and poorly attended to at home. On admission he was childish, facile, suspicious, and talka- tive. He thinks the house is coming down on him, that a surgical opera- tion was performed on him yesterday, and that people are watching him to do him harm, and many other changing fancies. He could walk, but dragged slightly the left leg. He had a paralytic, thick articulation. His heart was diseased. He steadily improved undor a good diet, regulated exercise and work, and general supervision, till in three months he left the asylum quite sane and able to. earn his own livelihood, though not strong-minded. He worked as a gardener for two years, and then was sent back to the asylum with much the same symptoms as at first. The mental symptoms and the hemiplegia again disappeared almost entirely, and in seven months he was able to leave the asylum. Though not able to work much, he has stayed quietly at home with his son ever since for three years now. Among the causes of paralysis and paralytic insanity, other than apoplexies and ramollissements, the most interesting in relation to the mental symptoms they produce are brain tumors. They are various in 282 PAEALYTIC INSANITY. kind, position, and mode of growth, and those conditions all affect the symptoms bodily and mental. Some tumors grow slowly, and their effects can be traced to intracranial pressure alone. In many such no symptoms have been present during life at all, or no symptoms that could lead to a correct diagnosis. Other tumors cause violent irritation, direct and reflex, in the brain tissues near and distant. Others cause destructive lesions, and especially ramollissements in the brain tissue near them. Others set up slow progressive changes both in near and distant parts of the brain and the organs of special sense. Intense cephalalgia is undoubtedly the most common sensory symptom. There are no headaches like those caused by tumors of the brain. They some- times stupefy and "drive the patient mad." Next to those, optic neuritis and blindness are the most common symptoms. The motor signs are paresis and paralysis local and general, convulsions local and general, and congestive attacks ; in these as in other respects, mentally and bodily, imitating general paralysis. The mental symptoms most common in cases with brain tumor are, first, irritability and loss of self-control, and "change of disposition," then depression, with or without excitement, then confusion, loss of memory, muttering to self, loss of interest in all things, perhaps delirious attacks, then drowsy half-consciousness, ending in coma and death. Such cases may die in a month, or may run on to twenty years from the beginning of the symptoms. Different authors have had extraordinarily different experiences as to the frequency of brain tumors from two per thousand up to twenty-eight per thousand deaths among the insane, which latter has been my own experience. It is doubtful whether brain tumors are more frequently found in autopsies in lunatic asylums than in general hospitals. The following is an interesting and very typical case 1 of insanity from tumor, which illustrates nearly all the common mental and bodily symp- toms of that disease: G. T., set. 38. First attack of insanity; no hereditary predisposition so far as can be ascertained; was intemperate in his habits, which is given as the predisposing cause of his insanity, the exciting cause being evidently organic disease of brain; has shown symptoms of insanity for four years. His first mental symptoms seem to have consisted in a change of temper, great irritability, and an altered affection for his wife and family. His first bodily symptoms were intense cephalalgia and a gradually increasing blindness, this last preceding by some time the mental alienation. He has been getting much worse mentally of late being excessively irritable, violent to his wife and daughters, very abusive and foul in his language, and then would accuse his wife of all the violence. He still drank hard when he could get whiskey, and all his mental symptoms were very much worse after drinking. He professed to be sorry for his violence and bad temper afterwards. The blindness became complete, and he also became slightly deaf shortly before his admission. During the twelve months before admission he had several "epileptic" attacks. He wished to go to the asylum, and walked there with a friend. 1 For this, along with other cases of mine, and more full observations on the mental accompaniments of brain tumors, see Journal of Mental Science, July, 1872. PAKALYTIC INSANITY. 288 On admission he showed slight signs of excitement and confusion of mind, but his memory was good. He was quite coherent, and, on the whole, sharp and intelligent. Could answer questions correctly, and had no delusions. He was a heavy-looking man, with the blind expression of face his features combining the expression of an advanced general paralytic and that of a man who is drunk. His gait was affected like that of a tipsy man. His speech was thick and rather indistinct. He was quite blind, and was deaf in his right ear. He said he had at times cramp in his legs. Reflex action in legs normal. Right pupil more dilated than left, and both nearly insensible to light. Lungs and heart normal. Appetite good, tongue very white, bowels costive, temperature 97.8, pulse 72, good. He remained in the state described for the first fortnight, except that on the very slightest provocation he became wild with passion com- pletely losing control over himself, and capable of doing any violence to those about him. In a fortnight he had a severe epileptiform fit, and was quite unconscious after it, but he was as usual next morning. He had such attacks frequently ever afterwards. For the first six months there was little change in him. After that he got more obtuse in mind, weaker and more paralyzed in his legs, his articulation thicker and more indis- tinct, his pharynx more insensible and paralyzed, so that he would have choked himself on any solid food. In nine months his legs were quite paralyzed, and his conjunctivas became at first injected and then ulcerated, with ulcers of the corneae. During the whole time he suffered from the disease, an excessive irritability with violent paroxysms of passion, often coming on without any cause, were his chief mental characteristics. Towards the end of his life, a clouding of his faculties took place, he slept much, and immediately before death he was semi-comatose. Reflex action in his legs continued very acute to the last. He died in ten months after admission, and about five years from the beginning of the disease. At the post-mortem examination the following appearances were found : HEAD. Calvarium hard and heavy, but not very thick. When it was removed a very curious appearance was presented. Over the surface of the dura mater there were a great many little cauliflower-like ex- crescences scattered irregularly, being most numerous along the middle line, and the largest in the locality of the Pacchionian bodies. The base of each was surrounded by a bulging of the dura mater, and where attached to this each was quite small, forming a short pedicle. They varied in size from a pea to a bean ; they looked like little projections of brain that had been made to squirt out through small holes in the dura mater by slow steady pressure from within little hernias of the brain. Each had a very thin fibrous covering continuous with the dura mater. In color they resembled a mixture of gray and white substance ; in consistence they seemed to be nearly that of ordinary brain convolu- tion. Each had a clearly cut bed absorbed out of the bony skull-cap, only leaving a transparent plate of bone. There was a large one over the right orbital plate, the size of a bean, causing complete absorption of the bone, so that it projected into the fat behind the eye. On attempting to raise the dura mater, it was found that this could not be done without 284 PARALYTIC INSANITY. tearing the connection of these hemiae with the convolutions. At the narrowest part of the neck of each, as it passed through the dura mater, it consisted of both white and gray matter, so that when torn oft" there was a small white spot like a pin's head in the convolution from which it sprung. On section it was seen that this white substance passed through the gray matter of the convolution like a stalk, and was continuous with the ordinary white brain substance ; and outside of the dura mater it ex- tended into each hernia, swelling out and forming its centre, with a thin covering of gray substance. By gentle pressure from without a consider- able part of some of the excrescences -could be pressed back ; the hernia could, as it were, be partially reduced, but this broke up to a greater extent what was evidently slightly softened brain substance already. When the brain was lifted up a large tumor was found attached to the right side of the cerebellum and along part of the right crus cerebri, pressing on, and causing partial absorption of that part of the pons Varolii and cerebellum. It was firmly attached to the fibrous portion of the temporal bone, causing absorption of the bone, and entering into and disorganizing the internal ear of that side. It pressed on the lower portion of the middle lobe of the cerebrum, causing complete ramollisse- ment there, so that the fluid in the ventricle ran out at that part. The tumor was hard and fibrous in some parts, soft and cystic in others, gray in color, and somewhat irregular in outline, being altogether about as large as a hen's egg. The ventricles were much enlarged, and contained much fluid. On section there were spots of ramollissement over right orbit, at base of middle lobe of right side, and in corpus striatum of right side, the white substance being generally doughy. Optic nerves and tracts gray and fibrous. MICROSCOPIC EXAMINATION. On a microscopic examination of the brain substance in the fresh state, the covering of each excrescence was found to consist of fibrous tissue, being thinned dura mater. The inside consisted of masses of granules, and in some places there was a striated appearance, being the remains of white nerve-fibres. The arteries were coated in most places with granular matter. On examination of the pedicles of the excrescences, the granular cells were not so numerous, and the striation of the white fibres was perfect. At the surface of the brain the appearance Avas that of healthy white brain substance. Altogether the morbid appearances were more marked at the outside of each hernia. On examining sections of convolutions, hardened in chromic acid, and cut and prepared by Stirling's method, it was found that the bloodvessels were very much enlarged and tortuous, and surrounded by granular matter and a great number of round vacant spaces in each section. Probably these had contained some morbid product, such as masses of granular matter, which had fallen out, or been dissolved by the turpentine and spirit in the process of preparation. STATISTICS OF PARALYTIC INSANITY. In the nine years, 1874-1882, we have had, out of 3145 admissions to the Royal Asylum, Edinburgh, 91 cases diagnosed as paralytic insanity. That is nearly 3 per cent. Of those 91 cases, 17, or almost 19 per cent., recovered mentally. This was one of the results of statistical inquiry into special forms of insanity that PARALYTIC INSANITY. 285 surprised me. Had I been asked before, I should have said that it was quite a rare thing for a case of paralytic insanity to recover. But this shows that when a gross lesion of the brain first occurs, it often sets up a convolutional storm of mania or melancholia, which is temporary and curable. The immediate mental effect is of the nature of a reflex irrita- tion, or temporary vascular congestion, which subsides like any other maniacal or melancholic attack. Ten cases were discharged more or less improved, in addition to the seventeen recoveries. Forty-six of the patients have died up to this time, in thirty-six of whom post-mortem examinations were performed. PATHOLOGY OF PAKALYTIC INSANITY. Looking at the pathology of paralytic insanity, as disclosed in the records of the pathological appear- ances found in those thirty-six cases, one sees that ordinary brain dis- integrations ("white and yellow softenings") from embolism and throm- bosis stand as the most frequent lesion. These "softenings" existed in eighty-three per cent, of the cases. Their most frequent original seat was in the basal ganglia, but in most of the cases the disintegration had extended into the white substance round those ganglia more or less. In only about twenty per cent, of the whole number was there manifest dis- integration of the convolutions. In four of the patients the lesion was confined to the convolutions, was, in fact, a true disease of the convolu- tions alone. These had been epileptiform. In five cases only were there adhesions of the pia mater to the convolutions, and in two of these the whole pathological appearances so resembled those of general paralysis that I think they had been instances of that disease, complicated by ordinary softenings in the basal ganglia. There was very marked atrophy, with or without softenings of the convolutions in twelve cases, or one-third of the whole number. Through atrophy, or adhesion of the pia mater, or disintegration, or the pressure of tumors, the convolutions were manifestly diseased in twenty-seven of the thirty-six cases, or seventy- five per cent. This gives so far a definite pathology to paralytic insanity, by showing that it is not merely through lesions of the basal ganglia and their reflex convolutional disturbances that it occurs, but through appre- ciable disease of the convolutions themselves, in three-fourths of the patients that die. I have no doubt that microscopic examination would have shown the convolutions affected in a still larger number of cases. The frequency of tumors was surprising. They were found in seven of the thirty-six cases. In most of them there was manifest convolutional secondary lesion, through pressure or irritation, in addition to the tumors. In one case a spiculum of bone projected into the pons from the base of the calvarium, setting up thickening and inflammatory action. The atrophy in two cases was of that kind which affected chiefly the white sub- stance in the centre of one hemisphere, leaving the gray substance of the convolutions like a crust round a hollow space (like the case figured in Plate V.). There were recent hemorrhages in only three of the cases : and there were purulent deposits in one. It may be concluded, therefore, that gross brain lesions, wherever situated, tend to cause mental disease in two ways first, by reflex or other irritation, or excitation of morbid convolutional action ; and, sec- ondly, by actual destruction, primary or secondary, of convolutional structure. LECTURE XI. EPILEPTIC INSANITY TKAUMATIC INSANITY. THE motor neurosis called epilepsy may exist in every form, and according to every definition, without being associated with such mental disturbance that it could be called insanity. Whether we hold epilepsy to comprise every motor spasm, even the slightest, or restrict it to the periodic recurrence of general convulsions accompanied by unconscious- ness, it may exist without insanity. But, on the other hand, in a very considerable proportion of cases, epilepsy has as its accompaniment mental disturbances, amounting often to insanity. And a very important form of insanity it is. Long before Dr. Skae classified mental diseases clinically, epileptic insanity was recognized and named. From the earliest times its mental accompaniments have increased the mystery and terror of epilepsy. When, added to the contortions and unconsciousness of that disease during a fit, there were afterwards developed strange hallucinations, terrible acts of impulsive violence, and striking religious delusions, we cannot wonder that a supernatural cause was almost universally believed in of old. No demon could by any possibility pro- duce more fearful effects by entering into a man than I have often seen result from epilepsy. The first great fact to be kept in mind, in regard to epilepsy in its mental relations, is that the frequent recurrence of epileptic fits for many years tends in some degree to impair the mental faculties, to dim the reasoning power, to twist or take the fine edge off the feelings, emotions, and sensibilities, to affect the memory, to lessen the self-control, and to change the " character," even where there is no actual insanity. If a man only takes a few fits in his lifetime, and they are far between, there may be no mental accompaniment whatever, except the unconsciousness at the time and the transient confusion after each fit. And, beyond a doubt, the occurrence of such rare fits is compatible with great mental power. Julius Caesar and Mahomet are said to have had such occasional attacks of epilepsy. When I speak of epilepsy causing insanity and mental symptoms, you must clearly understand that the whole series of symptoms, bodily and mental, may in some cases be the combined result of a general disturb- ance of function or of disease in the brain, neither the convulsions being the primary disease, nor the mania, but both being equally effects of the same cause. It is usual for the epileptic insanity not to follow at once the first appearance of the fits. Most commonly years elapse before it- comes on. No doubt the more severe and the more frequent the fits the greater is the risk of insanity, but certain epileptics suffer merely a gradual mental clouding and diminution after years of epilepsy, while others have furious mania very soon after the first fits have appeared. EPILEPTIC INSANITY. 287 It would seem as if certain cases of epilepsy from the beginning con- sisted essentially in their nature quite as much of a mental as of a motor instability and explosiveness. I do not agree with Hughlings Jackson that, in cases of petit mal and slight convulsions, the explosion, not finding vent in a motor form, is more apt to extend up into mental centres. There are some few such cases, but in my experience only a few. The theory is fascinating, but there is danger in making too close an analogy between a mental disturbance and an ordinary motor convul- sion, and in regarding them as virtually the same thing, the one being an ''explosion" in a "mental centre" and the other in a motor centre. I admit that such a view is most instructive as a hypothesis and help in making definite one's ideas, and in some rare cases of epileptic insanity seems to fit the facts exactly, and explain the apparently substitutionary character of the convulsion and the psychosis. But in nineteen cases out of twenty of epileptic insanity, the mental symptoms are not of the sudden explosive character at all, as we shall see, and they are by no means attended with unconsciousness or false consciousness, loss of memory, and want of power of attention. The theory of explosion assumes that you have a morbid energy developed in such brains that will act in some form, just like a charge of gunpowder, which, if you obstruct the muzzle, will blow out the breach of your gun. Epileptic insanity, and by this I mean all the morbid mental effects associated with the disease, occurs in relation to the fits in six chief ways : (1) After them. This is on the whole the most common, and the mental symptoms then seen are essentially periodic and paroxysmal, like the motor convulsions. They follow usually within twenty-four hours of the fit or fits. If there have been a series of fits, they are much more apt to occur than after one only. (2) Before the fits. They usually show themselves a day or two, rarely three or four, before a fit is coming on. And in such cases, when the fit occurs, the mental irritability, suspicions, impulsiveness, or confusion, usually disappears at once, its place being taken by a stupidity, or in some cases by normal mentalization. This is undoubtedly a strange fact, but is abundantly seen. Our attendants in asylums can tell in this way when a fit is coming on in many of the epi- leptics under their care. The fit, like a thunderstorm, seems to clear the air. (3) Mental disturbance may occur, instead of the fits, taking their place, apparently coming on at the period when the fits might have been expected. This is rare, but very instructive. It is the epilepsie larvee, or masked epilepsy, of the French, and seems to favor Hughlings Jackson's explosion theory of epilepsy more than any other clinical fact observed in connection with this disease. (4) A slow, steadily progressing loss of memory and change of affection, a blunting of the finer feelings, and a permanent mental obscuration or twisting, those being often the very first symptoms present, growing more intense the longer the patient lives and takes the fits. This is, in fact, a dementia either from brain injury by the fits or from the natural advance through prolongation of the morbid brain state that caused the epilepsy. Most epileptics tend to become demented if they live long enough. The arrest of mental devel- opment, and the degeneration towards idiotic conditions seen in nearly all cases where epilepsy occurs early in life, come under this heading. 288 EPILEPTIC INSANITY. (5) Some forms of chronic insanity take the place of the fits, which cease altogether. I have seen only four or five cases where this took place, and they all occurred at the termination of the reproductive period of life. (6) Epilepsy may begin in the course of chronic insanity of many years' duration, evidently through advance of disease from the mental into the motor centres of the brain. I do not mean a mere sporadic convulsion or series of convulsions, in the course of a case of recent or chronic insanity, such as I have described in that form of melancholia which I have called convulsive, or like those cases of alcoholic or syphilitic insanity in which convulsions play a part. I refer to those cases of chronic insanity, usually dements, who become epileptic, beginning to take regular periodic fits after being many years insane, and then going on taking them regularly. I have seen about a dozen such cases, and now have five such under my care. It will be observed that all these relationships point to a close connec- tion between the locus in quo of epilepsy in the brain and the seat of mental disturbance. The fact that they are related to each other in such various ways is the strongest proof of the nearness of their pathological seat. The experimental demonstration of a motor function in the convo- lutions seems to be strongly confirmed by all the clinical facts of epileptic insanity. Hereditarily ordinary insanity and epilepsy are closely allied. The son or daughter of an epileptic is just as likely to be idiotic, weak- minded, drunken, or insane, as to be epileptic ; and certainly the children of families with a strong insane heredity are very commonly epileptic. The actual mental symptoms caused by, or associated with, epilepsy vary considerably, as we shall see from the cases that will be related ; but there is a certain type of psychosis so common as to be almost character- istic. Two words express its most marked characteristics, irritability and impulsiveness. I suppose one may look on these as representing a morbid state of nutrition and energizing of the brain convolutions, whereby there is a morbid energy evolved and a want of inhibition to control it. The epileptic psychosis may exist in every degree from the merest excess of irritable temper up to the most dangerous homicidal impulses and acts. I have seen epileptic insanity take the form of a more acute maniacal condition than almost any other insanity. Before the days of the bromide of potassium, and its regular use in the cases of most epileptics in asylums, no patients were so troublesome or dangerous. There is no form of insanity that, outside asylums, is more frequently the cause of murders except, perhaps, the alcoholic. Hence its medico-legal importance to medical men and jurists. It depends much on the strength and intel- ligence of the medical evidence whether an epileptic murderer is hanged or sent to Broadmoor. If a man has been subject to regular epileptic fits, and commits a murder in an impulsive or motiveless way, then I think the presumption would be very strong that he was not fully responsible for his actions. No prejudice or want of knowledge on the part of judges or juries should prevent a medical man from giving clear evidence on this point. A murder by an epileptic should usually be looked on as being as much a symptom of his disease as larceny by a general paralytic. A certain religious emotionalism of a strong and usually perverted EPILEPTIC INSANITY. 289 kind is often present in epileptics. We have now a lad (C. W.) in whose anti-bromide, and therefore natural, epileptic clinical history it was a sure prelude to a fit, or series of fits, that he took his Bible, read it continu- ously, and when spoken to would answer fiercely " Don't trouble me, I'm a good man, I'm a servant of God." The day after, he would be walking up and down, striking any patient or anyone else who ventured to speak to him, replying maniacally "You're a d d liar! Don't insult me!" if one remarked to him it was a fine day. That night he would have one or two fits, and would be stupid and much inclined to masturbation. Next day he would keep his bed, and after a day or two would get up and go about as usual. The bromide treatment, in doses of twenty grains three times a day, has utterly destroyed the typical psychosis as well as diminished the number of fits, for he is now a mild, industrious, slightly weak-minded young man, who does what he is told, and only takes a fit every six months, instead of a series of them every month. As illustrating epileptic irritability not reaching this maniacal stage, look at those two women, G. X. and G. Y. The one, G. X., rages at her attendant, calls her a murderess, affirms that she has given her no food to-day (she has just had her dinner, eating half of it and throwing the remainder at the attendant), and that she has tried to poison her often. Nothing you can say to her but will rouse anger. No remark, however mild, but will excite a storm of scolding. No soothing influence will mollify her in the least degree. She tries to imitate your voice. She is sarcastic, abusive, and threatening by turns, as I demonstrate the failure of the psychological experiment of a soft answer being able to turn away wrath. By the way, that psychological aphorism is more applicable in dealing with the insane than almost any other class of human beings. It stands me in good stead many times every day; and if I could only practise it always myself, and get my attendants to prac- tise it, we should save many rows, and avoid on many occasions the use of physical force. But I am bound to say it altogether fails sometimes, and notably in this patient, and in other epileptics. But just try the opposite tack, and contradict her and tell her sharply that she is an unreasonable woman, who is talking nonsense and acting like a fool. How this aggravates all her symptoms ! She shouts, and at once threatens personal violence. "Never contradict or attempt to reason with an epi- leptic when excited," is an axiom in asylums. I wish we could get our attendants always to practise it. Now, this woman had a fit two days ago, and by to-morrow her irritability will have passed off, and she will be a quiet, civil, and agreeable woman. The next patient, G. Y., is in much the same general condition of morbid irritability. She sings a psalm tune in a noli me tangere tone of voice. When I ask her mildly what tune that is, she denounces me as a hypocrite and a scoundrel, says I am of the seed of the devil, and that she is one of God's people, and of the seed of Israel. This delusion recurs whenever she has fits. She describes visions she has, in which she sees Jesus Christ and the prophets. At times she has the hallucination that she is surrounded by flames, and sees eyes like fiery balls glaring at her. She is almost never amiable, is subject to morbid suspicions and 19 290 EPILEPTIC INSANITY. aversions to certain people. Her social instincts have been almost up- rooted by her disease. In both those cases the bromide has been tried, and failed to do good. This has partly resulted from the fact that the trial was imperfect, for they both believed it was poison given to do them harm, resisting and refusing it, and partly because the epilepsy they are both subject to is nocturnal. This is never so subdued by the bromides as the fits taken by day, and the epileptic psychosis associated with nocturnal epilepsy is also unamenable to the good effects of the drug. Epileptic insanity is not nearly so common among women as men, whatever may be the case with uncomplicated epilepsy ; and when it occurs it is less benefited by the bromides in most cases. 1 Next, let us take a case of typical epilepsy and typical epileptic in- sanity in a man, a patient that illustrates a great many clinical facts of an instructive kind: H. A. was said to have been thrown from his palanquin in India at the age of seventeen, and to have alighted on the left side of his head. He did not suffer much at the time, and had no epileptic fits till seven years afterwards when home on furlough. Yet on this slight post-hoc the epilepsy was put down to the fall in India. Relatives will always assign some cause for such a disease. There have been neuroses and mental disease, but no epilepsy, in the family. The fits began in March one year, and were numerous and severe. They usually came on about every month, but sometimes every day or two. In September following he had a severe maniacal attack, for which he was sent to the asylum. It was accompanied by unconsciousness, and a constant rotating motion from left to right, the eyes staring in a fixed, glassy way. His condition was, in fact, more a stupor with motor restlessness. This is not an uncommon kind of epileptic psychosis. This lasted for ten days, and he then got well. He had a pain in the left side of his head, especially before the fits, and his left arm in the fits, especially in the clonic spasm, twitched more than the right. It was thought that those things pointed to a depression of bone, or some such local irritation, at the part where he fell. The late Mr. Syme trephined the bone at the spot, taking out a circle about the size of a halfpenny. A "very questionable alteration" in the bone was thought to be detected. "No alteration was detected on microscopic examination." In a week he had a maniacal attack, without having any fits, during which he was most violent shouting, struggling, recognizing no one. To prevent him injuring the wound he w r as kept in bed by a number of sheets and skeins of worsted. This lasted for a fortnight, when he got well again. For three months he kept well, and was discharged from the asylum "relieved," having no fits for four months after the operation. He then became depressed in mind and emotional, weeping much. This, as a temporary phase of epileptic psychosis, is not uncommon. He then had several fits, which were followed within two days by an acute attack of mania, with frenzied violence. He was put in restraint in the sheets again, as his scalp was tender, and he threw himself against the walls of the room. As he got 1 For the exact statistics, see Journal of Mental Science for October, 1868. EPILEPTIC INSANITY. 291 out of the unconscious maniacal state he was irritable, unreasonable, and complained of everything. Nothing or nobody could please him. This was the very opposite of his natural disposition, which was most consid- erate and gentlemanly. In four months after this, he had a recurrence of the fits and a maniacal attack. He then took the fits occasionally during the next six months without there being any mania. But he was liable to sudden short attacks of epileptic psychosis, during which he would suddenly strike out at those near him, or his expression of face, would change and become furious, while he would stare at any one beside him, and shout fiercely " What the devil do you mean, sir?" This state would occasionally come on of itself without any exciting cause, but would sometimes be set up by contradiction, or when he saw anything done that he disapproved of. I remember being one of a party of four playing whist, he being one. We were playing quietly, not a word being said, when he suddenly let go his cards, stared at his partner with his eyes "rolling out of his head," and, with a damnatory exclamation, sprang at his throat over the table. He was seized, held gently on the sofa for a few minutes, came to himself, asked what had been up, and we went on with the game. He remembered nothing about what had occurred. This is what Hughlings Jackson would call an attack of "mental epilepsy." He then began to take the fits, about one every week, nearly always during the day. He was subject to various sensory neuroses, as most epileptics are, such as sensations of pins and needles in his limbs, a feel- ing as if there were twitchings in his head, especially after going to bed and before going to sleep, numbness in his left thumb, and tic in his right eye and temple. All sorts of treatment were tried for the disease morphia by mouth and subcutaneously, sulphates of zinc and copper, severe purgation, counter-irritation, colchicum, and alkalies, but while he seemed to be a little better for each drug, he soon was the same as ever. Occasionally he would pass two months without a fit, except perhaps a few attacks of petit mal. In 1865 he was put on the bromide of potassium in ten- grain doses three times a day. In a month he said he felt much better in health, had no nervousness, and little of the twitching feeling. His general health became better. For five months he took this, and had five fits in that time, only one of them being severe, and he had no maniacal excitement. The dose was then doubled, that is, he took twenty grains thrice a day. For one hundred days after that he had only two attacks of petit mal, then he had a slight fit. He kept so well in mind that, after a year of the bromide treatment, he left the asylum on probation, being charged to go on with the medicine. He stayed at home for six months, and did well. Then he began to take the fits rather more fre- quently, taking about two or three in the month of a slight character. He then came back to the asylum voluntarily, not being maniacal. The fits almost always come on just after waking or during sleep about 5 A. M., thus changing their character from day to night fits. Bromide acne used to trouble him, and he would on that account stop the medicine, but he always had a fit within three days after this. For two years he continued to take fits about every month or six weeks, but was never maniacal. Taking the fits in the morning, he entered into 292 EPILEPTIC INSANITY. the amusements of the asylum, playing billiards, cricket, dancing, etc. Of one thing he never could be made to realize the importance, and that was the risk he ran in dangerous places on account of a fit suddenly coming on. This was like all epileptics. He would constantly stand near the fire, or walk near steep places. When at a picnic at the Falls of the Clyde once, he went quite near one of them to look over. When warned of the risk, he coolly remarked that life would not be worth having if he were always thinking of the risks from a fit. It seemed to me the bromide treatment not only lessened the irritability of temper and the number of maniacal attacks, but that it prevented the mental degenera- tion in feelings and manners which long-continued epilepsy is apt to cause. He had a severe fit and a maniacal attack after it in 1870, for the first time for four years, during which he was most violent, sang at the pitch of his voice, and knew nobody. During this paroxysm he cut his hand severely with the glass in breaking a window. He had no severe maniacal attack after that for two years, though taking the fits. In September, 1872, he took a fit by day when standing with his back to an open fire ; he fell backwards, and burned himself most severely in the gluteal region, causing a sore of nine inches in diameter. For nine months after this, while the sore was discharging much pus, he had no fits, though taking no bromide. This I have seen very frequently in epileptics. Then his fits began again, but were very infrequent. His lungs then began to be affected. In about a year the wound healed, and then for the first time since the burn he had a mild maniacal attack. The lung disease gradually progressed, and he died in two years and a half after the burn. He had not a trace of mania and very few fits, for the last nine months of his life, during which his lungs were very far gone. On post-mortem examination, the dura mater was found adherent to the lower surface of the circular hole made in trephining the skull-cap, and was adherent below to the arachnoid and pia mater. There were no spiculse or thickenings of the bone towards the brain anywhere. On the left side of the spot operated on the pia mater was adherent to a brain convolution. The arachnoid was slightly milky, and there was consider- able vascularity in the brain substance, with some little perivascular atrophy. Otherwise the brain was normal, and the medulla was not congested, though the vessels were enlarged. The condition of the brain did not confirm the idea of an injury from the original fall, and threw no light on the cause of the epilepsy. In this one case you see there existed at different times, and under different circumstances, epileptic irritability ; epileptic mania with and without consciousness, the latter at times being wildly delirious and in the highest degree dangerous to the patient and those near him ; epileptic impulsiveness of action and violence ; epileptic stupor ; epileptic de- pression ; epileptic false consciousness ; epileptic automatism ; the charac- teristic epileptic want of realization of the dangers to which the liability to take the fits any moment exposes the patients ; epileptic sensory neu- roses ; the temporary improvements that counter-irritation and new modes of treatment are apt to produce in epilepsy ; the decided relief of many of the symptoms by the use of the bromide of potassium, which yet does not cure, and acts best at first ; the cessation of the fits and of the ten- EPILEPTIC INSANITY. 298 dency to maniacal outbursts when serious bodily diseases conie on ; lastly, the present unsatisfactory pathology of the disease was also illustrated. Epileptic insanity should be studied along with the symptoinatological class of impulsive insanity, with which it is very nearly allied in symptoms and heredity. I have already alluded to the case of E. L. (p. 238), so many of whose children died of convulsions, and whose brother is an epileptic patient in the asylum. It is also closely allied to somnam- bulism. Epileptic insanity proper is accompanied by, and complicated with, some of the most extraordinary and irregular mental phenomena. I have a man, H. B., who at times has hallucinations of smell, fancying the air is polluted round him by putrid meat ; another, H. C., who affirms that we cause itching and formication of his skin, he scratching himself violently after tits sometimes. I have known a " fit of itching " come on him instead of an epileptic fit. We have several epileptics who receive messages from the Deity after fits. I have a woman, H. D., who, before and after a fit, and while she is taking it, for she does not lose her consciousness, imagines she has two heads, and that one is under her own control and the other under the control of an enemy. In her case the fits are unilateral at first. I have a man, H. E., in Avhom an aphasic attack comes on and lasts for periods from one hour to three days, instead of epilepsy, he being meanwhile rational, cheerful, and industrious, and writing on paper anything he has to say or answers to questions. Suicidal impulses are not common in epileptic insanity. When present, they usually result from hallucinations of hearing voices telling the patient to commit the act. I had lately a well-marked case of this sort, H. F., a man aged thirty -nine when he was sent to the asylum, who had been subject to epilepsy for several years, and had often been maniacal. During one of his attacks he had bitten off his father's nose, under the de- lusion that he was calling him bad names. When well he was attached to him. He had exposed himself to some of the strongest causes of brain disease, for he had drank hard (epileptics very often do), had contracted syphilis, and exceeded with women, and, when a soldier in India, had been exposed to the sun and had sunstroke. When admitted he was very violent and homicidal. He heard voices, as if it were his fellow-patients calling him foul and offensive names, such as "thief," "scoundrel," "beggar," etc. He would often assault savagely men who were not speaking to him at all. He took the fits, which were of the ordinary character, about every fortnight. The hallucinations and homicidal tendency were usually worst before the fits, but he was always irritable, sullen, unsocial, and had a very strong and uncontrollable craving for drink and tobacco. He was put on the bromide of potassium in twenty- five-grain doses three times a day. At first it seemed to have no effect, but after about six months he became mentally changed for the better. He got chatty, amiable, and industrious. He had occasional outbursts of sullenness and irritability, but seldom was violent. He had the hallu- cinations of hearing very often, but he said he disregarded them, and latterly said he had got -himself to believe by reasoning that they were "voices" only, and not the words of actual men. If he took liquor, he was always worse in temper and conduct, and was apt to have morbid suspicions and hallucinations badly afterwards. At times he would 294 EPILEPTIC INSANITY. request to be put into his bedroom alone, to be quiet and out of the way of the temptation of assaulting his fellow-patients. After being in the asylum two years he had a short paroxysm of mania, and broke open his room shutter and got out, but was recaptured before he went away. He afterwards said that the voices had been telling him to go and throw him- self over the Dean Bridge, which is the chief temptation to dramatic suicide in Edinburgh. He improved much after that, and took no epileptic fits ; on one occasion, for eighteen months, never needed seclu- sion, got the parole of the grounds, and went into Edinburgh so see his relations occasionally. No suicidal attempt was ever thought of by me in his case. The fits had become slightly more frequent, however, in spite of the bromide. When out one day he went into town for a walk with two fellow-patients, was perfectly cheerful, and even jovial ; met his brother, and chatted pleasantly with him, saying he would be out again "next Saturday." On his way home he said to his companions that he was going to a urinal, went down a by-street, and then as straight as he could go he made for the Dean Bridge and threw himself over, killing himself instantly. This was two years after the time he said the voices told him to do so, and for twelve months before he might have gone and done so any day, so far as any restraint in the asylum was concerned. On post-mortem examination, I found the pia mater over the whole vertex of the brain strongly adherent to the convolutions, and the ven- tricles granular, just like a typical case of general paralysis. In fact, I never saw any case of that disease with those pathological appearances much more marked. The homicidal acts of epileptics are done under the most various cir- cumstances, are widely different in character in different cases, and even in the same case at different times, sometimes are done reasoningly from conscious insane motives, sometimes apparently, but not really reason- ingly, because without consciousness or memory. An epileptic may scheme to do an act of insane violence and try to conceal it carefully afterwards. They are most apt to take unfounded dislikes, especially to their relations and those near them. The conscious anger will pass into the epileptic unconscious mania in a moment sometimes. One of the most extraordinary things I ever knew was this : A young epileptic, H. G., who was very friendly with me when he was well, used to dislike me very much when excited after fits. On one occasion the attendant found him and another patient contriving to make up a weapon, with which to assault me or the chief attendant, out of a stocking which the epileptic had taken off, put a stone in the toe of it, tied a string about this, ' and had then slipped it up his sleeve till he should have a chance of using it. When he got out of the epileptic mental condition, he was astonished when told about this, and said he had no recollection of it whatever, which I believed to be true. The combination with another patient, and the purposive combined preparation of a lethal weapon, all in a state of epileptic unconsciousness, I could not have believed possible had I not seen them in that patient. Supposing this man had not been in the asylum and had combined with another in preparing a weapon, waiting for an opportunity, and had committed murder ; and then supposing a doctor had gone into the witness-box and given evidence that the murderer EPILEPTIC INSANITY. 295 was quite irresponsible on account of his being in a state of epileptic insanity, and quite unconscious of his acts at the time, with what lofty scorn would the judge have put aside such evidence as being inherently incredible ! With what dogmatic assertion the newspapers would point to such an example of a medical man trying to defeat justice and screen a criminal ! What lively ridicule the journals would have poured upon evidence so "opposed to common sense and to law!" And all this because a fact of nature and of disease had been brought out before those who were ignorant of the whole subject. PATHOLOGY. As regards the pathology of epileptic insanity, it is, like the pathology of epilepsy, as yet very obscure. I have met with innu- numerable brain lesions of almost every kind in different cases, and, on the other hand, I have most carefully examined the brains of many epileptic insane persons, and have found no special lesion or abnormality. I have found the following amongst other lesions, viz., spicula of bone from the skull-cap and membranes pressing into the convolutions, apoplexies, destructive lesions of the brain of all kinds and in all places, embolisms, fatty and otherwise, adhesions of the pia mater to the convo- lutions, the marks of traumatic injuries of all kinds and in all places of the brain, unequal hemispheres, and congestion of all sorts and in all places. I have tried my best to confirm Schroeder van der Kolk's observations as to the medulla and pons being always congested or diseased in epileptics. I have certainly failed to do so, and do not believe that it is the case. The general result of my pathological obser- vations is, that any source of irritation in a brain of a certain quality may cause epilepsy, but that an irritation to the motor area of the convo- lutions is infinitely more apt to cause it than one anywhere else. The coordination of the convulsions, the unconsciousness, and the breathing difficulties of the actual fit, may arise in the medulla, but the real origin of the convulsions is usually higher up in the brain. To have epilepsy we must have an inherent motor instability in the convolutions, just as we must have essential mental instability in the convolutions in order to have insanity. The epilepsy is an occasional dynamical disturbance, that may be the result of a constant pathological lesion, or of an inherently morbid brain constitution. It is a remarkable fact in epilepsy that one hemisphere of the brain is in nearly all cases found considerably heavier than the other, and that in by far the majority of the cases of infantile paralysis or unilateral development, where one hemisphere of the brain is larger and more perfect than the other, such patients are subject to epileptic fits. TREATMENT. As to the general treatment of epileptic insanity, it is that of epilepsy with that of mania superadded ; and with special pre- cautions to combat the special dangers I have described. Give the bromides regularly and steadily as you give food to your epileptics. Find out the dose for each case that will saturate but will not bromize, which will be from forty to seventy grains a day in different cases. Half bromide of potassium and half of sodium, with one or two minims of liquor arsenicalis to each dose, makes a capital combination. It can be given for years. I have known it continued now for fifteen years in a case, with immense benefit and no harm nil that time. Some few cases 296 EPILEPTIC INSANITY. will not be benefited at all, but four-fifths will be so more or less, and one-half will be benefited very much, while one-fourth will be so much benefited as to be practically cured, so long as they are kept under treat- ment. Its use will very often save epileptics being sent to asylums. Any physician to an asylum who does not keep most of his epileptic patients continuously under the influence of the bromides deliberately disregards one of the best proved therapeutic facts, for I have proved by experiment that he can reduce the fits to one-sixth, taking all the epileptics in an asylum together, and practically cure some cases, while most are improved mentally. Any physician out of an asylum who has an epileptic to treat, and sends him into an asylum without trying the effect of the bromides, does not, I think, give his patient the best chance known to science. Many patients will at times become bromized, but the white tongue, mental hebetude, and slow muscular movements of this condition can be easily seen in time before much harm is done. Intermittent bromide treatment is of little or no use. It must be continuous to do much good. Why the bromide does good to epileptics is as yet not ascertained in an absolutely definite scientific way ; but my belief, founded on a most ex- tensive experience of its use, is that its therapeutic effects are closely connected with its physiological actions of (1) diminishing the irritability of nervous tissue; (2) lessening the blood-pressure in the capillaries; (3) diminishing the sexual desire and the reproductive power; (4) pro- ducing a slowness in the mental operations allied to the phlegmatic tem- perament. In addition to the bromide treatment, dietetic regulation, the avoidance of surfeits, plenty but not too much exercise, life in the fresh air, no excitement that can be avoided, and no alcohol, are all useful. I have several epileptics who will almost certainly take fits or become irri- table if they go to a dance or get two glasses of whiskey. Blisterings and setons do good in some cases, while ergot and conium, especially if com- bined with chloral and the bromides, will control outbursts of excitement. The moral treatment must be soothing but firm, with no arguing, sharpness, imperiousness, or useless verbal contradiction. There is a procedure in the management of cases of epileptics subject to maniacal attacks that I look on as of the greatest importance as tending to prevent attacks of mania coming on. It is founded on the natural history of the disease. After an epileptic fit of the graver kind, a patient is always necessarily unconscious at first, then stupid and confused, and then sleepy, and if he is favorably situated he goes off into a very sound sleep. This seems to me nature's mode of restoring the disturbed cerebral circulation and recuperating the exhausted organs. Even after the sleep, most epi- leptics feel tired for a time. Now, by carefully giving an epileptic the chance of sleeping after his fits, by putting him on a sofa and darkening the room, we aid nature in her efforts to get over these effects. When the patient will not sleep, but shows signs of being restless and excitable, give him twenty or thirty grains of chloral, with a drachm of the bromide, and put him to bed in a dark room. The chances are he will sleep soundly and long, and will wake up all right. I have seen this plan succeed in apparently averting an outburst of epileptic mania dozens of times. As regards the results of treatment, they are in one way unsatisfactory from the risk of relapse, and in another way satisfactory, because the EPILEPTIC INSANITY. 297 patients may go home from asylums and earn their livelihood, and enjoy their liberty for long periods, often for life, if they will persevere in suit- able treatment. A patient recovered from epileptic insanity may, while he is well, be quite as well as a woman recovered from puerperal insanity. Our results in the Morning-side Asylum for the ten years 187381 have been that out of one hundred and twenty-eight cases admitted, thirty-one, or twenty-four per cent., have been discharged recovered of their epileptic insanity, and with the epilepsy itself greatly modified. Most of these have been able to remain at home. And it must be remembered that the cases sent to asylums are the worst cases of the disease. The milder cases with infrequent attacks are often treated at home very satisfactorily. LOCAL PREVALENCE. Epileptic insanity prevails very differently in different parts of this country. In the southern agricultural counties of England, where wages are low, life is stagnant, food is not too abundant, and beer is almost universally used as a part of the dietary, epileptic insanity is unusually common standing over eleven per cent, of all the admissions, and in some individual counties forming about one-fourth of all the inmates in the county asylums of those counties. This includes the epileptic idiocy and imbecility, as well as the cases where the epilepsy arose later in life. In such parts of the country the former kind of epi- leptic insanity prevails much more than the latter. In the better-off mining and manufacturing counties, such as Durham, Glamorgan, Staf- ford, etc., and in some counties of mixed population, such as Sussex, the proportion of epileptic insanity in the admissions is only about five per cent. Clinically, epileptic insanity is more acute and typical in those districts. In the large cities of England it holds an intermediate place, forming about eight per cent, of the admissions to the asylums of those cities. In Scotland it prevails to a less extent than in England. In the admissions to the Royal Edinburgh Asylum, whose pauper patients are drawn entirely from a city population, only four per cent, have labored under epileptic insanity during the past nine years, and only seven per cent, of our present inmates are of this class. In other parts of Scotland it is still more infrequent. (The following is the general summary and conclusions of my experi- ments made in 1867 to determine the precise effects of the bromide of potassium in epilepsy and epileptic insanity:) Twenty-nine cases of epilepsy of old standing, all having the same diet, and subject to the same conditions, were subjected to systematic treatment by bromide of potas- sium, after their normal condition as to fits, weight, temperature, general health, and mental state had been ascertained and noted. 1 gave them gradually increasing doses of the medicine, from five grains up to fifty grains, three times a day, and the treat- ment was continued for thirty-eight weeks, every essential particular in regard to the disease and their bodily and mental condition being noted every week during that time. The total number of fits taken by the patients fell gradually under the use of the medicine to one-sixth of their average number without medicine. The fits taken during the day were lessened to about one-twelfth, and those taken during the night to about one-third of the previous number. The reduction in the fits was not uniform in all the cases. In one ca-e it amounted to twenty-four thousand per cent., in one-half of them to more than one hundred per cent., and in five cases there was no reduction at all. In one-fourth of the cases the fits were much less severe, in some being less severe, while as frequent as before. 298 TRAUMATIC INSANITY. In one-fourth of the cases, the patient's mental state was very greatly improved. Nervous and mental irritability and tendency to sudden violence were wonderfully diminished in those cases, and they were the worst of the patients in that respect. Attacks of epileptic mania were diminished. In some cases the mental state was improved, while the fits remained as frequent as ever. The majority of the patients gained considerably in weight while the doses were under thirty-five grains, three times a day. Their aggregate weight was greater at the end of the thirty-eight weeks than it had been to begin with, though it began to fall after thirty-five-grain doses had been reached. The patients' average temperature fell somewhat until they got to fifty-grain doses thrice a day. The pulse gradually fell about seven beats up to forty-grain doses. After that it rose, but not up to its usual standard without medicine. None of the patients suffered in their general health except five. All the others were benefited in some way. The ill effects produced by the medicine in those five cases were torpor of mind and body, drowsiness, increase of temperature, loss of weight, loss of appetite, and in three of them slight double pneumonia. The cases most benefited by the drug were very various as to the causes, number, and character of the fits, age, and in every other respect. On the whole, the cases who took most fits benefited most. The cases in whom the medicine had ill effects had all taken fits from childhood, were all very demented in mind, and took more than one fit per week, but seemed to have nothing else in common. The diminution of the fits and all the other good effects of the medicine reached their maximum in adults at thirty-grain doses, three times a day, while ill effects were manifested when thirty-five-grain doses, three times a day, were reached. There seemed to be no seriously ill effects produced in twenty of the cases by fifty- grain doses of the medicine, thrice a day, continued for ten weeks. When the medicine was entirely discontinued for a month in all the cases, the average number of fits increased in five of the cases benefited to or beyond their original number, in thirteen cases they remained considerably less. The average number during that time was a little more than one-half the number of fits taken before the medicine was given, and the greatest number of fits occurred in the second week after the medicine was discontinued. TRAUMATIC INSANITY. A few cases of mental disease are caused by blows on the head, falls, and other traumatic injuries to the brain. Sunstroke also causes in- sanity, and the general mental symptoms of traumatism and sunstroke are apt to be alike. No doubt, sunstroke gets the credit of far more insanity than it produces. Few Englishmen become insane in hot climates, in whom that cause is not assigned. My experience is that traumatic insanity is to be found in two forms. The first form is the more characteristic type of the disease. It is accompanied by motor symptoms, either in the shape of speech difficulties, slight hemiplegia, general muscular weakness, or convulsions. Usually in such cases there are, in addition, sensory symptoms, such as cephalalgia, vertigo, halluci- nations, a feeling of confusion and incapacity for exertion of any kind, mental or bodily. The mental symptoms are usually a form of melan- cholia at first, tending in time towards an irritable and sometimes impul- sive and dangerous dementia or delusional insanity. In my experience, such cases are all absolutely intolerant of alcoholic stimulants, a very little of which will always make them maniacal, and often very dangerous and even homicidal. Many of them have a craving for stimulants, too, which they indulge, and which aggravates all these symptoms. It is TRAUMATIC INSANITY. 299 surprising what a number of the traumatic cases are complicated with alcohol, in having been addicted to drink before these accidents, or taking to it after. Over one-half of my cases were so complicated. In either case, whether a drunkard falls and injures his brain and becomes insane, or wh ether a man takes to drink and becomes insane after an injury, the alcohol aggravates the mental symptoms, and tends more strongly towards incurability than mere uncomplicated traumatism. A few cases become ordinary epileptics. I have two epileptics in the Royal Asylum now who have large depressed fractures, and I have seen several more on the post-mortem table. In one there had been a fracture above the ear, where the bone, membranes, and brain all adhered by an old inflammation. I have seen three patients now, in whom the motor symptoms were so exactly those of general paralysis that I diagnosed them as such, but they turned out to be non-progressive, though not curable paralytic cases ; and now, after over ten years, they are alive, and no worse than at first. One man, H. H., fell off a ladder, and fractured the base of his skull, was unconscious for long, and seemed afterwards to become a true general paralytic from this cause, but his symptoms did not progress. Another, H. I., a drunkard, received an injury to his head, was unconscious, and seemed to become mentally and bodily a most typical general paralytic, but the motor symptoms never progressed. As I mentioned, traumatism is one of the rare causes of true general paralysis. I had one such case that was caused by a railway collision, but then the man, after the accident, attempted to study and enter a profession with a weakened brain and an impaired memory. Within three years he became a general paralytic, and died of the disease. Usually the motor symptoms of traumatic insanity are non-progressive, or very slowly so. But they do not always manifest themselves at once after the injury. I had one patient, H. L., who was not made uncon- scious at all by the blow of a piece of wood falling on his head, but who gradually in three months got weaker on one side, as well as being muscularly weak all over, and also mentally impaired in memory, energy, and volitional power. He was also very irritable. Certain very interesting cases have been recorded of insanity directly following fractures of the skull, with consequent pressure on the brain, which were cured by trephining or raising the depressed bone. One of the most striking of these was published by Dr. Charles Skae. 1 It was that of a miner Avho received a depressed fracture of the skull about three inches above the left extremity of the left eyelid, was unconscious for four days afterwards, then went to work, but within a fortnight exhibited a change of disposition and habit. Instead of being a sociable, merry, good-natured man, fond of his wife and children, he became at first irritable, moody, unsocial, and suspicious, and then excited and danger- ous, and then acutely maniacal. He was sent to the Ayr Asylum, and two months after admission, during which time he had not improved, an operation was performed by Dr. Clarke Wilson, by which the depressed portion of bone was removed. A gradual improvement in mind took 1 Journal of Mental Science, vol. xix. p. 552. 300 TRAUMATIC INSANITY. place week by week after this, until in a short time he was as sociable, lively, and cheerful as ever, and has continued so ever since. Such cases are very suggestive of thought and inquiry as to the pos- sible reflex and direct irritations that may be the causes of mental disease in many cases, and they clearly show that the dynamical brain disturb- ance which we call insanity may sometimes originate in special points of local brain irritation. The condition of the urine as to sugar and albumen should be carefully tested in all traumatic cases. Where sugar exists there is room for grave suspicion of mischief to the pons near the floor of the fourth ventricle, though this can scarcely be diagnosed with certainty in this way. Some cases of idiocy result from injury to the brain by the forceps during delivery, and I have two now in the Royal Asylum resulting from falls on the head in early childhood. The other and less distinct class of traumatic cases are those in whom an injury to the brain acts as an exciting cause of an ordinary attack of insanity in a person predisposed to the disease in fact where traumatism acts like a moral shock. As the result of a bout of drinking or some such disturbing cause of brain action after traumatism, I have seen attacks of mania and melancholia in patients from which they recovered perfectly ; and, on the other hand, I have now under my care several cases of ordi- nary dementia, and one of chronic mania, and one of delusional insanity, all incurable, and originating in traumatism, but without any motor sensory signs, and without progression of symptoms. I once saw a young man, H. M., of nineteen, who had an attack of ordinary acute mania just after being in a railway accident, and presumably caused by it, but by which he had not been made unconscious, or even stunned. I have now a case of suicidal melancholia, H. M. A., set. 46, resulting directly from an injury to his head through a piece of stone falling on it from a height of ten feet, and then his falling twenty feet on the back of his head off the scaffold on which he was working, cutting the skin over the occiput, but neither injury causing prolonged unconsciousness. This occurred three months ago, and ever since he has been able to do no work, has suffered from a dull feeling in his head and much pain in his back. His mental condition became gradually depressed. His attention was concentrated on his ailments until he was quite melancholic. He became suicidal, fancied he passed only blood from his bowels, which was a de- lusion ; and that his food did him no good, he being fairly nourished. There are no motor signs, and his temperature is normal, the reflexes being also normal, but he does not sleep. He gradually improved under treatment, until he became well in mind and body and able for his work. PREVALENCE OF TRAUMATIC INSANITY. We have had twelve cases of traumatic insanity and the insanity of sunstroke sent to the Royal Edinburgh Asylum in the past nine years, which is only one-third per cent, of the admissions. Accidents to the head do not loom largely there- fore in the production of the insanity of the world. LECTURE XII. SYPHILITIC INSANITY ALCOHOLIC INSANITY. THE mental as well as the bodily symptoms of brain syphilis have attracted more attention on the Continent than in this country, though of late years a greater medical interest has been awakened here in regard to this subject by the writings of Reade, Buzzard, Broadhurst, and Douse, but above all by those of Hutchinson and Hughlings Jackson. It is a large subject, because the functions affected are numerous ; an obscure subject, because the effects of the disease are often very slight and slow in development, and are multifarious in kind ; and is an interesting subject to the alienist, because it is a disease in which the mental and bodily symptoms can after death be often directly connected with the pathological lesions present, and because in some cases the resources of therapeutics are most powerful and direct in curing the disease. In regard to the frequency of syphilitic affections, there is the most extra- ordinary difference of experiences among different authors. Douse makes the astounding statement that, of ten thousand patients under his treat- ment at the Central London Sick Asylum, three-fourths were the subjects of acquired or hereditary syphilis. That statement is enough to make one shudder. Its import, if a fact, to the mental and bodily future of London is appalling. Whatever may be the frequency of ordinary syphilitic affections, all authors agree that brain syphilis is rare, abso- lutely and relatively. Dr. Wilkes first pointed out "that when the primary and secondary manifestations of syphilis are least marked, the viscera and nervous system are affected in an inverse ratio ;" that is, we find that in a large number of cases of brain syphilis there have been few primary or secondary symptoms, and no traces of the effects of the disease in the viscera. My own observation confirms that of others, that the syphilis which ultimately attacks the brain or its membranes, has often lain for many years entirely latent, or apparently so, before it produced any symptoms at all. I think there is no doubt that a hereditary pre- disposition towards the neuroses determines the effects of the poison towards the brain. In addition, injury to the brain, previous disease, venereal excesses, over-study, mental anxiety or worry, and even fright, may all act as determining causes of brain syphilis. Lancereaux states that the learned professions are especially liable to it. Looking at the matter from a purely pathological point of view, "syphilis of the nervous system," though a term often used, is, strictly speaking, a misnomer, for Hughlings Jackson has shown that the poison never really attacks the nerve tissue proper at all, but only its neuroglia, fibrous tissue, bloodvessels, lymphatics, membranes, or bony coverings, involving the nerve tissue and its functions secondarily, by pressure, so 302 SYPHILITIC INSANITY. causing irritation, inflammation, and ramollissement, or by starvation from deficient blood-supply, and so causing degeneration and atrophy. Brain syphilis with mental symptoms is in this unique position, that in the most characteristic cases its pathology is much more definite than its symptoms. The pathological changes may involve any and every part of the brain, and in any and every degree. The symptoms, there- fore, mental and bodily, depend on the position and on the intensity of the morbid process. We may have the most acute and delirious mania caused by a rapidly growing destructive syphiloma in the convolutions, or we may have a mental enfeeblement so slowly progressing that it takes twenty years to run its course, caused by an obstructive arteritis gradually closing up the lumen of a few of the cerebral bloodvessels. My own experience would lead me to classify syphilitic insanity into four forms ; and here I am conscious of the disadvantage I am under in having chiefly to do with the mental symptoms of brain syphilis, instead of having to treat of the whole subject as a pathological entity with its whole bodily and mental symptoms. The brain syphilis that has bodily symptoms only I have nothing to do with, though its pathology and treatment may be precisely the same as the mental cases, the only differ- ence being the locus in quo.* The mere sketch I am able to give here of the mental symptoms will by no means exhaust the great variety of psychological phenomena met with in this disease. The first form may be called secondary syphilitic insanity. It occurs during the second stage of the disease, is coincident with the eruption, is curable and rare. Dr. Cadell * has described a typical case. A gentle- man contracted an infecting chancre in January. A squamous syphilide appeared in April, and along with it, marked mental excitement, and an extreme amount of motor restlessness, this maniacal state reaching its height in August and September, and then almost amounting to delirium. " The patient took no rest in bed, was in the habit of riding and driving about recklessly during the night." This maniacal excitement gradually diminished, until in December the patient appeared to be in his normal mental state, this being coincident with the gradual disappearance of the syphilide. In the following April, an attack of mild suicidal melan- cholia with "paralysis of energy," came on, and lasted for over a year, this being coincident with the falling out of the hair of the head, eye- brows, and beard. With the disappearance of all traces of the syphilis and the restoration to bodily health, the mental state also became normal and remained so. I have now a case, H. 0., a young woman of twenty, who seems to have contracted syphilis either just before or just after her recent mar- riage, and on admission to the asylum showed the characteristic eruption of the second stage, with sore throat and reduced condition. For eight days before admission she had been maniacal, and when sent here was almost incoherent, very uncivil, and foul in her language, being especially erotic and nasty in her ideas. She had, as well as the syphi- litic eruption, bronchitis, with some amount of pleurisy. She was put on iodide of potassium, with a little mercury and tonics, and nutrients. 1 Journal of Mental Science, vol. xx. p. 564. SYPHILITIC INSANITY. 303 She gradually improved in mind, the syphilitic eruption passed away, but her lung disease went on, and of that she died within six months. Now, such cases might be thought to be mere coincidences of an attack of mania with one of syphilis, were they not too common for this, and were the beginning and termination of both diseases not so contem- poraneous. I presume such moral causes of insanity as fear, remorse, and shame, come in and help the blood poison to start the psychosis in such cases sometimes. But it would be strange if the infection of the system and of the blood with such a virulent and vile poison did not sometimes derange the functions of the convolutions in persons predis- posed to insanity. This form of syphilitic insanity has no known pathology. Its treatment is that of secondary syphilis, and its prognosis is good. The second form, the delusional syphilitic insanity, is one due, in my opinion, to slight brain starvation and irritation from syphilitic arteritis that has become arrested. It consists of an incurable monomania of suspicion or of unseen agency, with hallucinations of the senses, but without motor symptoms, following at some distance of time an attack of syphilis in persons strongly predisposed to insanity. It seems as if, in fact, the syphilitic poison had produced a subtile dynamical change in the brain convolutions and their trophic energy, as well as the arteritis, mani- festing itself in unreason, hallucinations, and an organic feeling of ill- being. Dr. Hugh Grainger Stewart published several graphic cases of this kind. One of them imagined that he underwent a kind of a nightly torture called by him the "cylinder finish;" another said that most ingenious machines were introduced into her brain to torture her ; another that people shot vitriol, ammonia, and "black poison" at him all night, to avoid which he wedged his bedroom doors, covered the key-holes with blankets, stuffed his ears and nostrils with cotton-wool, and his mouth with a pocket handkerchief, all these defensive measures against his imaginary bombardment taking him an hour to carry out before he went to bed. I have several cases of the same kind under my care just now. One is a woman, H. P., a prostitute, who thinks there is a network of wires in her brain, put there by me. Another, a gentleman, H. Q., strongly predisposed to insanity, his only sister being insane, who, a year or two after a bad attack of syphilis, and while some of its consti- tutional effects still remained, developed delusions of a conspiracy against him, and that people affect him sexually at night. Uuder the influence of these delusions he became dangerous. Such cases are, in my experi- ence, always incurable. They are liable to be complicated by alcoholic and phthisical causes of brain disturbance. I admit that it may fairly be asked about such cases Can we not have those symptoms without the occurrence of syphillis at all from mere heredity taking this develop ment? I think we can. Or is there such proof in any of those patients that have been syphilitic that this poison or its trophic effects were really the causes of the mental derangement ? In many of them certainly the time between the supposed cause and its effects was long, and altogether the scientific proof of their connection is Aveak. Still the coincidence of this type of case with previous severe attacks of syphilis is certainly very marked in a large number of cases. There is a general resem- 304 SYPHILITIC INSANITY. blance between the mental symptoms of such cases and those of the case of "vascular syphilitic insanity" (case of H. S., p. 305), where actual disease was found in the arteries of the brain. The next two forms have a very definite pathology. One, the third on the list, may be called the vascular syphilitic insanity., and the fourth the " syphilomatous insanity." 1 The one depends on the tendency of the poison to affect the bloodvessels of the brain and cause slow arteritis, with diminished blood-carrying capacity and consequent slow starvation of the cerebral tissue. The other depends on the tendency of the poison to affect the connective tissue, neuroglia, membranes, and bones, and cause pressure, irritation direct and reflex, and inflammation in the con- volutions. Any other causes of arteritis, or tumor, or pressure, or irrita- tion than syphilis, would probably produce somewhat the same mental symptoms, and, as a matter of fact, some of those mental symptoms follow non-specific arteritis and tumors, and also traumatic lesions of the brain. Yet the syphilitic cases, though not absolutely pathognomonic, are nearly so in most instances. Of the vascular syphilitic insanity I give the following cases out of many I have met with, because the} 7 are very typical : H. K., when he was a student, was infected with syphilis, which ran a bad course, and many of its somatic effects never left him, e. g., copper-colored spots and baldness, and, as we shall see, his liver was the seat of an old gumma- tous deposit. He entered the church, married, and procreated several unhealthy children. In twelve years after his attack of syphilis he became changed mentally and morally, showing a morbid irritability, threatening violence to his wife and children, disregarding the decencies of life, and the proprieties of his social station and profession, going about his parish telling improper stories, and not conducting himself rightly in regard to some of the female members of his congregation. On admission to the asylum, his mental symptoms were those of simple coherent "reasoning mania." He had stricture, copper-colored blotches on his skin, and irregular baldness. After being in the asylum a month he affirmed he had several "fits," but there Avas no proof then of con- vulsions. He was untruthful, malicious, showed no natural feeling, and no self-respect. He was a year in this asylum, and was then transferred to another. His mental power steadily deteriorated; he became subject to regularly recurring convulsive seizures ; after some years he had, along with general weakness, a partial paralysis of the left side, with incon- tinence of urine, thickness but not tremulousness of speech. Mentally he passed from irritability into enfeeblement and loss of memory ; from that into stupor, in which state he died thirteen years after he first showed mental symptoms, and twenty-five years after he had contracted the attack of syphilis which had been at the root of all his ills. On post-mortem examination the calvarium was found condensed, and the right side of the frontal bone thicker than the left. The dura mater was much thickened, congested, and adherent to the bone and to the pia mater, and this last to the brain convolutions, so that the dura mater could not be removed without lacerating the convolutions. This was par- 1 Mr. Hayes JSTewington, Journal of Mental Science, vol. xii. p. 555. SYPHILITIC INSANITY. 305 ticularly the case over the parietal and frontal lobes. On section, a great part of the centre of the anterior lobe of the right hemisphere, and many of its convolutions, were found to be atrophied, the place of the neurine, white and gray, being taken by a flocculent, gelatinous, fibrous material. The outer layer of the gray matter of those convolutions was found to be normal looking. On the left side of the brain the white matter was generally lacking in consistence pale in some places and congested in others. The lining membranes of all the ventricles were very granular. The basal ganglia on the right side were softened and congested. An examination of the arteries of the brain showed a hypertrophy of all the coats, causing extraordinary obliterations of the lumen in places, irregular contractions, and nodulated thickenings. Every form of irreg- ular local arteritis was found, all the vessels being more or less affected, but especially the branches of the middle and anterior cerebral passing to the atrophied part of the right hemisphere. The spinal cord was found to have undergone general atrophy with anasmic and softened portions in the dorsal region, and intensely con- gested portions in the lumbar region. The dura mater, pia mater, arach- noid, and cord were all matted together in some places. The liver was found to be puckered with cicatrices, and to have a small gummatous tumor the size of a bean in one portion of it. It was evident that here there had been a syphilitic inflammation of the membranes ; but the great bulk of the mental and bodily symptoms could be traced to the effects of the arteritis causing first irritation in the brain convolutions and then a slow process of blood starvation. The real character of the case was never diagnosed during life. In the following case the arteritis seems to have ceased to get worse at a very early period of the disease, and its effects mental and bodily were therefore almost stationary for thirty-five years: H. S., 1 set. 30 on admission. Patient had a severe attack of syphilis at seventeen, for which he was treated with mercury. After this he was always irritable, and sometimes violent. On one occasion he attacked his mother, and smashed the door of a neighbor's house with a poker, and, when taken to the police office, that night had a partial hemiplegic attack. He was for ten years in a private asylum at Musselburgh, and then was taken to Morningside. On admission, he had delusions of suspicion, impulsive- ness, violence, and also hallucinations of hearing, fancying he heard voices calling him "low," "mean," and seeing figures that he imagined jumped down his throat. He was taciturn and melancholic, too. In three years his delusions were worse. He seemed to have had a slight difficulty of speech, and he imagined a woman had located herself in his mouth and was the cause of this, as well as of a bitter taste in his mouth. His gait was a little unsteady, straddling, and ataxic, and he dragged one leg a little. His bodily condition was never strong, and he looked weary and pale, and he always suffered more or less from dys- pepsia. His delusions, impulsiveness, and excessive irritability of temper continued for the twenty-six years he lived in the asylum ; and superadded 1 This case was more fully reported by the late Dr. J. J. Brown, then assistant physi- cian, Eoyal Edinburgh Asylum, in the Journal of Mental Science, July, 1875. 20 306 SYPHILITIC INSANITY. to these there was considerable general enfeeblement of mind. His legs got weaker before death in 1875. He died of diarrhoea. The brain membranes were thickened, a thin layer of blood-clot was found under the pia mater, and the convolutions were much atrophied. There was a small cyst in the pons, evidently from old apoplexy. The microscopic appearances were the most striking (see Plate VIII., Figs. 1 and 2). The arteries in the pons were thickened, the muscular coats being hyper- trophied to an enormous extent, the outer coat being also much thickened, and in and around this coat was a molecular deposit (Plate VIII., Fig. 1) containing also granular masses, this deposit in many instances filling up the peri vascular space. At some parts the vessels were patent, at others completely occluded, and the lumen absent, the artery presenting the appearance of concentric rings in the centre of a granular deposit. The gray matter of the convolutions was found to be degenerated, the cells being atrophied, and their spaces in many instances being occupied by a few granules (see Plate VIII., Fig. 2). The spinal cord was also affected in the same way in its arteries, and in its gray and white substance. There were many microscopic apoplexies in the white substance of the cord. No better demonstration of chronic vascular disease of syphilitic origin, and its effects of brain starvation, degeneration, and atrophy, with the resulting mental suspicions, hallucinations of hearing, and lack of self- control, could have been afforded than this case. I have seen some of the most extraordinary pathological effects in the brain from slow syphilitic arteritis. I have several specimens of brains in which the whole of the white substance in the inside of the anterior and middle lobes, lying between the outside convolutions and the central ganglia, had gradually and entirely disappeared, leaving a vacant space filled with fluid and a few fibrous flocculi. The gray substance of the convolutions, looked at from the inside in an antero-posterior section of a hemisphere, presents the most extraordinarily defined appearance, just as much so as when looked at from the outside (see Plate V.). The convo- lutions looked as if the white substance had been carefully pared off them, leaving the gray matter intact. The effect was exactly what would have resulted had that portion of brain been steeped in a fluid which had the power of dissolving away the white substance and leaving the gray entire. The cause of this is no doubt the histological facts that (1) the gray substance of the convolutions has five times the amount of capillary blood-supply of the white ; and (2) the source and mode of supply is different, the gray substance getting it from the already divided and anastomosing net- work forming the pia mater, and the white substance getting its supply from single vessels, which in dividing form only an infrequent anasto- mosis, and a network with large, long meshes. The white substance, in fact, slowly dies, and disappears through an arteritis which only causes partial atrophy, anaemia, and lessened mental function in the gray con- volutions. Looking at such a brain, many questions suggest themselves. How do the convolutions act whose white fibres of communication inwards and their interconvolutional fibres have quite disappeared? Is there a general power of conduction in the convolutions from one through the next, and so on till it reaches one whose ingoing fibres are intact ? Can PLATE V PLATE VIII. G.WatprstoaiSons Litho .Edinburgh SYPHILITIC INSANITY. 307 the convolutions still act in some degree even deprived of their projection and association system of white fibres? Most of the vascular cases have the general course of H. R. Mentally a change of character, morbid suspicions, loss of self-control and of the moral feelings, a disregard of the decencies of life, then an intense irri- tability, often with violence and a loss of memory, then an enfeeblement of the mental power, ending in complete dementia. Bodily, an unhealthy and cachectic general state, a lack of trophic power, with no cephalalgia necessarily, then a general failure of muscular power and a tendency to partial paralysis, then occasional epileptiform fits, sometimes unilateral, but never more localized than a motor paralysis that advances and recedes in a puzzling way, then loss of power over the sphincters, loss of trophic power, and death, if that has not occurred before through an attack of convulsions. The duration is very different in different cases, but in my experience it is never less than five years, and may be twenty-five. If one was fortunate enough to be able to diagnose a case in the earliest stages, no doubt the iodide of potassium, with nerve tonics,, nutrients, and brain rest, should be prescribed, and I think I had a case where these measures saved the patient from going further than mild and manageable childishness, without tendency to convulsion. But if the lumen of an artery has been lessened by slow syphilitic arteritis, we have no reason to think it can, by any therapeutic means, be made more patent ; and if some of the brain tissue has already been starved into atrophy, most certainly it would be a groundless hopefulness to think of its possible restoration. Looked at purely from the pathological point of view, the arteritis may affect vessels of any and every size down to capillaries, may thicken the fibrous or the muscular parts of the arterial wall, or any of the coats. It is usually irregular and local, and often nodular. I do not know any more instructive demonstration of the visible effects of a lack of blood supply on brain cells and fibres than may be found in sections from dif- ferent parts of a brain affected by syphilitic arteritis (Plate VIII., Fig. 2). The fourth or sypJiilomatous form is so exceedingly various in its symptoms, mental and bodily, that I really do not know where to begin. It may consist of a syphilitic meningitis attended with a temporary stupor and delirium, which is most curable by the iodide of potassium. Or it may consist of a quick -growing syphiloma within a convolution, that causes in a few weeks extensive softening, wild maniacal excitement, general convulsions, and paralysis, and speedy death ; the whole process being from the beginning absolutely beyond the reach of cure, or even of alleviation. Or it may consist of local gummata, causing pressure, local convulsions, mental irritability, and very slowly progressive dementia. Or it may consist of great cakes of syphilitic inflammation and gummatous or semipurulent deposit over one or both hemispheres, causing gradual dementia, and at last coma. Or it may be a membranous or bony tertiary lesion that has been quite arrested in its growth, but has set up what is practically epilepsy and ordinary epileptic insanity. I shall just give an idea of the disease by referring to a few cases. I shall first illustrate the more acute forms by the following case of syphilitic tumor of rapid growth within the substance of the brain : 308 SYPHILITIC INSANITY. H. T., aet. 26, a prostitute, whose history was not known except that she had been deliriously maniacal, cephalalgic, and had taken convulsive attacks. On admission to the asylum she was vacuous and taciturn, and almost in a condition of stupor. Her pupils were unequal, but there was no motor paralysis visible. She wakened up partly, and spoke in a slow, hesitating way. After being in the asylum for a month, and taking many convulsive attacks during that time, she died suddenly one day after such an attack. A small gummatous tumor was found in the centre of the anterior lobe of the right side, involving one of the frontal con- volutions, and this was surrounded by a great ring of white softening and brain anaemia, and that again by an outer ring of congestion. I had lately another case very similar to this, H. U., aet. 41, with no ascertain- able history of syphilis, but who had had several miscarriages. Her uncle had been a patient in the asylum. For a year she had suffered from intense cephalalgia, mostly on the right side, passing to the forehead and affecting her sight. For six months she had had fainting turns, and for three weeks convulsive attacks. On admission she was mentally con- fused, complained of voices round her bed, and talked wildly and inco- herently about things that had no connection with the questions asked her. She began to take convulsions a fortnight after admission, and died of these in three weeks. I had during life diagnosed brain tumor, prob- ably syphilitic. After death we found under the dura mater several hemorrhagic patches. The convolutions presented a flattened "glazed" appearance. Section of the brain showed great pallor of the white sub- stance of the left hemisphere. In the lower and middle part of the left internal capsule there were two small gummatous tumors, one the size of a big bean, the other the size of a filbert. They were surrounded by an area of loose, disorganized, softened brain substance, involving the an- terior third of the corpus striatum, spreading through the temporo- sphenoidal lobe, the whole of which was pulpy. The softening extended also along the posterior horn of the lateral ventricle. In the right hemisphere there was also an abnormal pallor, but there was no softening except in the posterior lateral ventricle, which presented much the same appearance in a less degree as on the left side. There was no tumor or deposit on the right side. This exemplified what is very commonly found in the brain, viz., a symmetrical lesion on both sides of the brain in exactly the same place. My experience is that vascular and atrophic lesions of the brain, such as apoplexies, large or capillary softenings, and thrombosis, are exceedingly apt to occur in both hemispheres in the same places and almost at the same time. This vascular and tropho-organic sympathy of the two hemispheres, extending to diseased conditions, is a most important fact not noticed in pathological works, but physiologically and pathologically it must be kept in mind in brain study. In both the above cases the cerebral bloodvessels seemed normal. A small, local, quick -growing syphiloma in the brain substance had caused surrounding destruction by pressure and irritation, setting up an inflam- matory process, and causing tissue death. The symptoms had been cephalalgia, convulsions, mania, confusion, loss of attention and memory, SYPHILITIC INSANITY. 309 and sudden death within a short time. I have since met with two cases of the same kind of much slower course and without convulsions. The next example I shall take of brain syphilis is one that most physicians would not be inclined to regard as one of "insanity" at all, though, as a matter of fact, the patient was incapacitated for work, con- fused and stupid in mind, and at times delirious. But, being a clear case of brain syphilis of a common type, with mental symptoms cured at home by appropriate treatment, it is more important to the practising physician than cases with more decided mental symptoms. H. V., set. 33. Patient's mother had been insane for a year, " after a fall on the head." He had had syphilis six or seven years ago, with few secondary symptoms. He had not been feeling well for six or seven weeks, suffering from very severe headaches. Three weeks ago he took suddenly a very severe attack of general convulsions with unconsciousness. Before that he had on several occasions a rather pleasant momentary feeling of " being in a trance," and this sensation preceded the fit. When taken home after the fit, he was confused and had severe cepha- lalgia, and had slight left hemi-paresis. He went to the late Dr. Begbie, who prescribed iodide of potassium in five-grain doses. Since then he had travelled about a little, and tried to do business, but could not do so properly on account of loss of memory, lack of power of attention, general confusion of mind, and severe cephalalgia. When I first saw him, he was considerably paralyzed in the left side ; he had double vision, and a loud noise in the right ear ; he was confused, mentally depressed, his memory very poor ; he was irritable, wayward, tending to be violent, and difficult to manage. If he had been a poor man, he would probably have been sent to an asylum at once. He suffered the most fearful cephalalgia, especially at night, and the slightest tap, especially over the right side of his brow, greatly increased his sufferings. The skin of the right side of his head and face was hypersesthetic, and his right conjunctiva injected. He could not read or write. Pulse 80, temperature 98.4. Appetite gone, tongue much furred. I put him at once on ten-grain doses of the iodide of potassium, with fifteen grains of the bromide, and one-twelfth of a grain of the bichloride of mercury thrice a day, with milk and potass water alone for diet. For about a week he got no better, suffering the most fearful agony in his head at night, becoming delirious, and wanting to go out at the window. I tried chloral in twenty-five-grain doses re- peated every two hours, as well as the bromides and tincture of cannabis indica, in large and repeated doses, to dull the night pain and procure sleep, but with only very temporary relief. In the mornings, after those medicines, he was always more confused and irritable, and had no ap- petite. By far the best thing I found for easing the night cephalalgia and procuring sleep was to make him lay his head on a rubber bag of almost unbearably hot water. After a week the cephalalgia abated, he got a little more sleep, he became less irritable and confused and less frequently delirious, and he looked better, but the paralysis did not improve for a fortnight, and then I raised the dose of the iodide to fifteen grains three times a day. In three weeks the double vision ceased, and he began to walk and grasp better. The cephalalgia became merely paroxysmal, and took the form of neuralgia of the supra-orbital branches 310 SYPHILITIC INSANITY. of the fifth nerve. He became less sensitive to tapping his head, his tongue got clean, and his appetite so ravenous that I had much difficulty in keeping him from eating flesh diet. In a month he was still further improved, could walk, read, and dictate a little, and was able to be out in the open air, though any exertion, mental or physical, produced a sense of intense exhaustion. The noise he had in his right ear disap- peared about that time, and also a feeling of cold on that side of the face. In five weeks he was almost convalescent, and mentally normal, though he had on two occasions the "trance" feeling that preceded the convul- sions. In two months he had what was evidently a syphilitic inflamma- tion of the periosteum over the mastoid process of the right temporal bone. He omitted the iodide for a week at my advice, but at once he began to feel worse in all respects mentally and bodily. I then increased the dose to twenty grains three times a day. This he took steadily for two years without showing a trace of iodism ; on the contrary, getting fat and strong, and mentally vigorous. A dimness of vision in the left eye and a tendency to pains and slight weakness in his left side on damp days, were the last of the symptoms to disappear. After two years I finally stopped the iodide, after having several times tried to do so before with bad results, and he keeps well and fit for business, with just a trace of head symptoms at times. This was no doubt a case of syphilitic inflammation and thickening of the membranes of the brain over the right hemisphere, affecting the cor- tex of the organ and its functions mental and bodily by pressure and inflammatory irritation. There was no doubt a gummatous deposit there. The beneficial effects of large doses of the iodide, and the tolerance of those doses for so long after the symptoms had apparently disappeared, is the common experience in these cases. The mental symptoms were characteristic in all respects. I have had other cases of this kind, not put under treatment so soon, which have gone on for years partially paralyzed, subject to convulsions, and at last dying. In one such case (H. U.) I found a cake of gummatous semipurulent material covering the whole anterior portion of the vertex, causing pressure on the convolutions, and destructive softening of their outer layers. The calvarium was soft, eroded, and spongy. In another case still in the asylum (H. X.), recorded by my then assistant, Mr. Hayes Newington, 1 the patient had syphilis when young having a necrosis of a portion of the left side of the osfrontis, which healed up however. During her married life she had four still-born children, and then three living ones. At the climac- teric period she began to take epileptic attacks, which have continued periodically ever since, the convulsions always beginning at the right side. She was at first periodically maniacal, with hallucinations of the senses and severe pain in the seat of the old necrosis, and she has gradually become demented, with occasional exacerbations of maniacal restlessness and talkativeness in fact, she has become an epileptic dement. In such cases, as Mr. Newington says, " there is little doubt that syphilization stands as the first link of the chain of factors, and, of course, the 1 See Journal of Mental Science, vol. xix. p. 555. SYPHILITIC INSANITY. 311 insanity (now dementia) may be regarded as the last" that last link not being forged till thirty years after the first. In the following case a syphilitic tumor of slow growth pressed on the brain, eroded the bone, and caused the usual mental and bodily symptoms of brain tumor : H. Y., 1 aet. 47 ; history unknown. He had been a wanderer over the earth. He had the marks of syphilitic disease. He was depressed, confused, irritable, had no memory, and his general mental power was enfeebled. He was restless, with an unsteady, shuffling gait, and had vertiginous and epileptiform attacks. His left arm was subject to involuntary and uncontrollable twitchings, with pain if the arm was held steady ; slight left hemiplegia in leg, with partial left facial paralysis. He had slight anaesthesia of left cheek and arm, shown by his not being able to localize a pin prick there. When pricked in left arm he felt it in left thigh ; this parsesthesia, however, disappeared in three or four days. There was at the summit of the parietal eminence on the left side of the head a tender spot, which, when tapped, caused the left leg to be thrown into a state of convulsion and twitching, the patient still remaining conscious. He had copper-colored patches over his body, and a small tumor in right groin. He was put on large doses (twenty grains three times a day) of iodide of potassium, with small doses of the bichloride of mercury, but with no benefit. He died, a month after admission, in an epileptiform attack. On post-mortem examination it was found that there was an erosion penetrating the skull-cap, making a hole through it of an oval shape, nine-sixteenths inch long by five-sixteenths inch broad, where the ten- derness had existed during life. The dura mater was adherent round this point, and enormously thickened being a quarter of an inch thick at some parts. I often come across such thickenings of the dura mater in the bodies of the insane, and they cannot be considered specific. On the removal of the dura mater a hard gummatous tumor was seen in two nodules, together about the size of a pigeon's egg. The brain convolu- tions round this had been pressed so as to cause some atrophy and softening. I have never seen a syphilitic tumor of the brain where the cerebral substance round it and in contact with it was sound, while I have seen all sorts of other tumors, even of large size, embedded in normal- looking brain substance. The tumor by its pressure outwards had caused the erosion in the skull-cap. It involved chiefly the supra-mar- ginal convolution, and also to some extent the ascending parietal. The angular gyrus was also involved. Out of thirty one hundred and forty -five cases of insanity of all classes of society admitted into the Royal Edinburgh Asylum during the past nine years, sixteen have been cases of syphilitic insanity, or about one- half per cent. Few of these recovered, or are likely to recover, the majority of the patients being far advanced in their disease before admission, with serious involvement of the structure of the brain. 1 Case reported in Journal of Mental Science, July, 1879, p. 216. 312 ALCOHOLIC INSANITY. ALCOHOLIC INSANITY. I do not speak here of the use of alcohol as a general cause of all /'kinds of insanity. J[t jsjinfortunatel^_the > roQst common of all the causes Jof thfi_disas,e, in some cases^proHucing^t de ^oz^4oujtber!rt5rlging^into : activity hereditary and acquired brain weaknesses. From fifteen to 4 twenty per cent, of the cases of mental disease may, taking the country through, be put down to alcohol as a cause, wholly or in part. As a cause of insanity it is not followed by constant results. Conditions of mental depression, of exaltation, of enfeeblement, of stupor, of morbid impulsiveness, may all be caused by it. General paralysis, paralytic insanity, epileptic insanity, adolescent insanity, and climacteric and senile insanities may be due to alcohol as exciting causes of the attacks. When so caused, we do not call these alcoholic insanity. I have no time to speak here of those most interesting degenerations of individuals and of races that follow the excessive use of alcohol. Two great French alienists, Morel 1 and Moreau de Tours, 2 have told us nearly all we know of that subject. They looked at the insanity as one of the effects of evil conditions of life, of bad and insufficient foods, of the use of all sorts of neurotics in changing for the worse the type of human being in the first and in the succeeding generations. There are few of the unfa- vorable conditions of life that by themselves cause more human degenera- tion than the excessive use of alcohol. Many of the American Indian tribes, fine races to begin with, have been simply killed off by it in a gen- eration or two, degenerating in body and mind all the time. You are aware of the pathological tissue-degenerations that are caused or promoted by it, the atheromatous, the fatty, the cirrhotic changes that take place in the vascular, the renal, the hepatic, the glandular, the fibrous, and the nervous tissues. Those are the individual tissue and single organ damages. The whole organism suffers somatic and mental lowering, alteration of function and of energizing. These degenerations are transmitted from generation to generation in the same or other forms by hereditary laws, if not corrected by neAv and improved conditions of life. In some individuals they are mere potentialities and tendencies, in others they have assumed definite forms, and become insanity, idiocy, stuntedness of growth, ugliness, deformity, deaf-mutism, sterility, incapacity for high kinds of education, immorality, and lack of general control. Those are large general ques- tions, of the highest interest socially and physiologically. They often become very practical questions to medical men. Alcoholic degenerations influence the type of all ordinary diseases, and they interfere much with the treatment adopted for their cure. When our profession becomes, as it should be, and as I have no doubt it will in time become, the guardian by prophylaxis of the physical and mental well-being of the people, and the great source of authority for the regulation of the conditions of life, such questions will come far more to the front than they do at present, and they must then form an important part of medical study. 1 Traite des Degenerescences de 1'Espece Humaine. 3 La Psychologie Morbide. ALCOHOLIC INSANITY. 313 Meantime I have merely to describe and illustrate those forms of mental disease, in which alcohol has not only been the cause, but has so influ- enced the symptoms that they are in some way special or peculiar, so that the mental and bodily results are, as it were, specific, and so may be called alcoholic insanity. No agent that I am aware of has such dif- ferent results on different brains as alcohol. For that reason alcoholic insanity is not in all cases of the same kind. ACUTE ALCOHOLISM. The most typical alcoholic insanity is Delirium Tremens, or acute alcoholism. That this is described in ordinary text- books on Practice of Physic, and is treated usually at home or in general hospitals, and is of short duration, does not make it less a true insanity. From a symptomatological point of view it is a typical excited or motor melancholia, characterized especially by hallucinations of sight, fleeting delusions of all kinds, but especially delusions of suspicion, suicidal feelings, partial or complete incoherence, failure of memory, great con- fusion, tendency to mistake identities ; in some cases by unconsciousness, and by loss of power of attention. It is the bodily symptoms that give it its most characteristic features. The motor restlessness and the motor tremulousness combined are excessive and constant. In addition the temperature is usually above 100, there are paralysis of the appetite for food, often sickness, generally lack of digestive power and assimilation, a rapid loss of body-weight, and absolute sleeplessness. In typical cases, and in the first or second attack, it runs a somewhat definite course, and has a short duration measured by days or weeks. Such cases are now often certified as insane and sent to asylums for treatment, and but for the idea connected with an asylum they are best treated there. We have the means of treating them more satisfactorily there, according to the present ideas of treatment, than in a hospital. We have trained at- tendants, suitable rooms, grounds for exercise, and no necessity for the use of narcotics used merely to keep the patient quiet and manageable. The patients often recover sooner with us than in hospitals, chiefly because we can keep them after the first day or two in the open air. I do not recommend patients suffering from acute alcoholic insanity to be sent to asylums if they have money enough to have good skilled attend- ance, and can be sent to a lodging in the country or outskirts of a town after the first few days, simply because the notion of having been in a lunatic asylum is repugnant to most men's feelings, and it may be more injurious to a patient afterwards than if he had been treated in a hospital or at home. It would be easy enough for all large general hospitals to have some rooms and an exercise ground for the treatment of such cases. The chief difficulty is the expense of keeping a permanent staff of two good trained attendants for work that would be only occasional. Here is a good case of acute alcoholism sent to an asylum. J. A., set. 34. Has had several attacks of the same kind before. Drinks in bouts, not steadily. Is of an excitable, sensitive disposition naturally. Has been ill for about a week, during which he has not slept. Is chat- tering incoherent nonsense, addressing imaginary persons in short, snatchy, semi-incoherent sentences. His attention cannot be roused to attend to the questions put to him ; evidently has hallucinations of hearing and of sight. He looks up at the ceiling and round the walls as if following 314 ALCOHOLIC INSANITY. some object with his eyes, and turns and says, "Yes," "What is it?" etc., as if in answer to questions or remarks. He is very restless and tremu- lous, so that he cannot hold a cup to his lips and drink out of it without spilling. The temperature is 101, pulse weak and quick, skin perspiring, eyes sunk, expression of face haggard and almost vacant, pupils dilated but sensitive, tongue tremulous and coated. His articulation was markedly tremulous, like that of a general paralytic, only thicker. The reflexes were dull, and the spinal reflex action almost gone in this last respect differing from nineteen out of twenty general paralytics. His general strength was very low. He was put to bed and fed with milk, and effervescing potass water, alternated with beef-tea. He was made to take those things by attendants contrary to his inclination. He was sent out to walk assisted by an attendant for an hour the first day, and that night he was fed every hour irrespective of his inclination. He scarcely slept. Next day he was fed regularly, and was out in the open air most of the day. His pulse got stronger and he slept two hours that night, and his temperature fell to 100. The same treatment was adopted day by day, and no medicine was given him but quinine and nitro-muriatic acid, which were prescribed after the first two days. In four days he was coherent and less tremulous, and could sit still. In a week he was ra- tional, and in ten days he was well, all but the sense of exhaustion. Some cases do not turn out so well. There are five chief risks from the alienist's point of view that I have met with. The first is that of the brain passing from a melancholic mental condition into that of stupor and coma. This takes place in very bad cases that have soaked and lived on alcohol for years. I had a great, stout, flabby -looking woman, J. B., once, whose case took this course, and she died in ten days. She had had alcoholic convulsions before admission, and had been dosed with opium. We found intense brain congestion, thickening of the mem- branes, and the outer layer of the gray matter of the convolutions dis- eased microscopically, being full of proliferated nuclei. The second risk is the persistence of the hallucinations of hearing after most of the other symptoms have gone. This is apt to occur where there have been many previous attacks, and a neurotic heredity. The treatment is exercise in the open air and mental distraction from morbid fancies. Most of them will so recover in a month or two. The third risk is the persistence or aggravation of the insane suspicions of poisoning, of conspiracy, or of being worked on by electricity and unseen agency. In fact, the case becomes one of delusional insanity. This is very common, especially the delusion of poisoning. This arises out of a misinterpreted sensation. There is chronic gastritis or indigestion from alcoholic irritation of the mucous membrane of the stomach, and the patient attributes his bad sensations to poison. I had one man, J. C., who retained for years the delusion that I had put rats inside him, but he recovered through proper regimen and abstinence. Such cases, as well as those with the persistent hallucinations of hearing, are frequently very suicidal, and need care and watching on that account. The subject of the danger of suicide in all kinds of alcoholic insanity has not been at all sufficiently dwelt on. I believe that more suicides, and combined suicides and homicides, result in the country from alcoholism in its early stages than from any other ALCOHOLIC INSANITY. 315 cause whatsoever. The fourth risk is that the man's brain and the man himself gets out of the attack with the finer points of his moral character and feeling rubbed off. He is mentally different from his former self, though not insane. He is more untruthful and unfeeling, coarser in the grain, more lazy, and less honorable. His brain has undergone an or- ganic change to some extent. Instead of fine membranes, they are milky and thickened ; instead of pure brain substance, it is mixed with pro- liferated neuroglia and adventitious tissue. The fifth risk is run in patients who have a heredity to insanity, and who have frequently had alcoholic insanity. Instead of the attack resolving itself in the natural way, it runs into an attack of ordinary melancholia or mania, which ends in dementia. In fact, there are few cases that pass into dementia at once out of the attack of acute alcoholic insanity, or even without this a de- mentia characterized chiefly by a loss of memory, a listlessness and in- action, and yet a coherence and apparent power of reasoning not seen to be unreal till you test them. Such cases have been soakers for years. I have one such gentleman now, J. D., who once had a powerful intel- lectual brain, well stored with literature and professional knowledge. He drank steadily for over twenty years, and then had an attack of alco- holism, with symptoms of kidney degeneration and hepatic cirrhosis. He now talks very rationally, dilates on the cruelty of his being in an asylum, and on his being ruined by being kept from his business. He has no de- lusions, and, if you give him the cue, will repeat half a play of Shakes- peare's, and tell you all that occurred to him twenty years ago ; but when you ask him the day of the week, or what he had for breakfast, he cannot tell you in the least. When I say to him (and this has been my stock answer to his complaints of improper detention for ten years), "Well, Mr. , write to the commissioners and state your case," he will reply, " I'll do so at once ; there never was such an outrage com- mitted on a man before." Yet, in ten years, he has never written to the commissioners, though a lawyer. He wanders lazily about our grounds, of which he has the parole, day by day, and is always happy in a negative way, except during the few minutes he dilates to me on the frightful cruelty of his being in an asylum. I had another such case, who could not, for a long time, remember his own name. His brain had to be re- educated to this simple act of memory. Such patients are usually fat and torpid in movement. They have lost the fine lines and movements of facial expression. Their affective nature is dulled or twisted. They often have lost the craving for stimulants in this state. CHRONIC ALCOHOLISM. The next form of alcoholic insanity is that condition commonly known as chronic alcoholism. This is also always accompanied by motor signs, many cases indeed not being technically "insane." It is often ushered in by alcoholic convulsions. A long- continued, steady soaking in alcohol is, I believe, much more damaging to the brain in its mental, motor, and trophic functions than bouts of heavy drinking with intermissions of sobriety. In chronic alcoholism, looked at, as I am doing, chiefly from the mental point of view, all the symptoms are less acute and last longer than those of acute alcoholic insanity. The suspicions and fears of the latter become a chronic symp- tom, the delusions are less numerous and more apt to become fixed. 316 ALCOHOLIC INSANITY. The hallucinations of sight are absent, but we are far more apt to have hallucinations of hearing. There is loss of inhibitory power, and there- fore tendencies to impulsive acts. There is sleeplessness, but it is not so absolute. There is motor incoordination, but not so much restlessness. The speech is thick and often tremulous ; the tongue very quivering and incoordinated in its movements. The functions of the cord are affected, causing a slightly ataxic walk and an abolition of the spinal reflexes, and sometimes of the tendon reflex. The temperature is usually about 99. The appetite is never keen, and the taste often perverted, so that the patient complains of food not being what it professes to be. Here is a typical case, J. E., set. 41, an innkeeper, whose brother committed suicide, and who has drank hard for many years whiskey being his liquor. His present attack began with sleeplessness, and restlessness, insane suspicions, and hallucinations of hearing. He thought his wife poisoned his food and kept men in the house, whom he would go and seek at all hours of the day and night in cupboards. When sent to the asylum (he attempted suicide on the way) he was almost sleepless, heard voices all about him saying he was to be destroyed and punished, and the voices of his wife and family. l3is temperature was 98. He was tremulous and shaky, and could not walk far. He could not write or drink out of a tumbler without spilling the contents on the floor. His tongue was foul, and very tremulous he could scarcely put it out at all. His appetite was gone, and he affirmed that the meat we gave him was the flesh of his children; he was put on the bromide of potassium and steel, was fed with liquid custards, which contained six pints of milk and ten eggs a day, in addition to some solid food. He was taken out to walk in the open air till he was tired three times a day, and he had a constant attendant by day and night to prevent him doing any harm to himself or others. Several times, without any warning and with no provocation, he has rushed at and broke windows, struck attendants, upset tables covered with dishes and jumped into our pond. He never could tell, after doing them, why he did these things. After three months' treat- ment he was scarcely any better. He would not read, or play games, or take any interest in anything, or speak to anyone except when spoken to. But in six months he is now much improved, and showing signs of recovery, which I do not expect to be perfect however. In such cases recovery is slow, and is very apt to be incomplete, if it occurs at all. A chronic degeneration of the whole of the brain plasma has begun. The intellectual power, the power of application, origina- tion, and independent energizing are weakened ; the delusions of suspi- cion are apt to persist ; the morals and self-respect are apt to be regained ; lying, stealing, and cowardice are indulged in. The affection for wife and children is impaired. These symptoms run on for a year or two, and then we have dementia supervening. But this termination is not invariable. First attacks are often recovered from in a way, even second attacks will be got over, but third and fourth attacks seldom completely. Instead of dementia, we have sometimes in young subjects delusional insanity supervening. I have one such man, with a tremulous tongue that he always put out to one side, who affirms he is "worked only by electricity," and hears voices; another who says his food is poisoned ; ALCOHOLIC INSANITY. 317 another who thinks everyone near him insults him in everything done ; another whose ribs are broken every night by unseen enemies. All these delusions, you see, are misinterpreted sensations. The treatment of such cases consists in the use of tonics of all sorts, of nerve stimulants such as strychnine, and the continued current for a time, and especially of rigid abstinence from alcoholic stimulants and the lead- ing of a controlled, regular physiological life in the open air, with garden work if possible. MANIA A POTU. There is a third kind of alcohdlic insanity of short duration, but great acuteness while it lasts, called variously mania a potu, or very expressively delirium ebriosum. It occurs in the cases of persons, often young, with unstable brains hereditarily. It takes very little drink to produce it ; and in many cases looks like a prolongation and exaggeration of that wild drunkenness which occurs in certain people who are said not to "carry their liquor well." A few glasses of spirits make them riotous and unmanageable, and often quite delirious, uncon- scious, and violent. Such brains have often shown a weakness from the beginning, such as lack of self-control, tendencies to be -easily led away into vice, incapacity for getting on. In some of them there exists a craving for stimulants, constituting the condition known as dipsomania. Mr. Hayes Newington, while one of the assistant physicians here, gave a capital account of mania a potu, with clinical illustrations. DIPSOMANIA. I have already treated of this condition in the lecture on conditions of defective inhibition (p. 250). ALCOHOLIC DEGENERATION. Lastly, I shall simply refer to the lowered mental condition that is apt to result from the too great indul- gence in alcohol, apart from technical insanity, or from an inordinate craving, or even from the notion of disease, bodily or mental, at all. A doctor of experience soon comes to observe in his patients and in his acquaintances a certain kind of change, mental, moral, and bodily, in the people who habitually "take more than is good for them." The expression of face and eyes is seen to be changed, the mental tone to be lowered, the power of application to be lessened, the self-control to be weakened. I am safe in saying that no man indulges for ten years continuously in more alcohol than is good for him, even though he was never drunk all that time, without being psychologically changed for the worse. And if the habit goes on after forty, the change is apt to be faster and more decided. We see it in our friends, and we know what the end of it will be, but we cannot lay hold on anything in particular. Their fortunes and work suffer, and yet you dare not say they are drunkards, for they are not. It all depends on the original inherent strength of the brain how long the downward course takes. Usually some intercurrent disease or tissue degeneration cuts off the man before he has a chance of getting old. I have seen such a man simply pass into senile dementia before he was an old man, from mild, respectable alcoholic excess, without any alcoholism or preliminary outburst at all. And I am sure I have seen strong brains in our profession, at the bar, and in business, break down from chronic alcoholic excess without their owners ever having been once drunk. 318 ALCOHOLIC INSANITY. I have seen many cases of insanity resulting from opium-eating, and one from the hypodermic use of morphia. They were very like the insanity of chronic alcoholism, but not so suicidal, with greater weakness of the heart's action, and more sleeplessness, sickness, and intolerance of food for the first fortnight. It is precisely the same class of persons who indulge in opium who indulge to excess in alcohol, and the treatment is the same, viz., an immediate stoppage of the drug, with much liquid nourishment, fresh air, and watching. I have seen two cases of insanity brought on by the use of chloral. They, too, were of the same generic type as the alcoholic cases, and demanded the same treatment. LECTURE XIII. KHEUMATIC AND CHOKEIC INSANITIES GOUTY INSANITY- PHTHISICAL INSANITY. THE first two varieties of mental disease may be conveniently studied together. There can be no doubt now entertained as to the close connec- tion between chorea and rheumatism ; as we shall see, this connection is shown very vividly in rheumatic insanity, Avhich is also an acute choreic insanity. Cerebro-spinal rheumatism has long been known, but in some of its types it does not come within the scope of a book on mental disease. In one variety, however, the most prominent symptoms are an acute delirious mania and choreic muscular movements of a violent char- acter. The ordinary course of an attack of rheumatic insanity is seen in the following case in a typical form. J. F., admitted January 17, 1870, set. 24, married. First attack of insanity. Mother died of consumption. Father alive and well, and no relative insane or rheumatic. In health she was of a reserved and quiet but nervous disposition, steady respectable habits, and fond of her chil- dren. The predisposing cause of her illness seemed to have been an accumulation of debilitating and depressing influences, viz., ill-usage by her husband, poverty, cold, hard work, with insufficient food during the three years since she was married, and having nursed her second child for fifteen months up to the period of her attack. These things caused a certain amount of depression* of spirits. The exciting cause of her malady was an attack of rheumatism, not of a very acute character, which had lasted for two months before she became insane. She had pains in the back of her neck, pains and much swelling of fingers, hands, feet, and legs, and some feverishness ; but she was never so bad as to be quite confined to bed. A week before admission she suddenly ceased to complain of her rheumatic pains, and simultaneously with this relief she showed signs of mental derangement, and violent chorea of head, arms, and legs commenced. Her first mental symptoms were a sort of absence of mind and inattention to what was passing around her, taking no notice of questions put to her or of her children. Before being sent to the asylum, in addition to this mental inattention, there was great excitement. She tore her clothes, and tried to jump out of a second-story window into the street. She was quite sleepless, and the choreic movements had increased greatly in intensity. Her limbs were never still a moment, and she threw her whole body about. She was much excited on admission, her memory almost gone, and with difficulty can be got to speak at all in answer to questions, but talks incoherently in monosyllables about the doctor who had attended her. The only question she can be got to answer is to tell her name. The 320 RHEUMATIC INSANITY. existence of delusions could not be ascertained. She is a dark-complex- ioned woman Avith black hair ; rather thin, muscles flabby. Eyes dark- brown and sparkling feverishly, pupils contracted, equal in size. There are very violent choreic movements of the muscles of her face, head, arms, and legs. Anything she attempts to say or do voluntarily is accompanied by extravagant grimaces, twitchings, and contortions. Reflex action is diminished. Cannot articulate more than single words at a time, and those imperfectly. Cannot stand or walk, and was carried with great difficulty ; no tenderness of spine ; lungs normal, respirations twenty per minute; heart beating quickly but regularly, no cardiac murmur. Pulse 108, strong. Tongue clean and moist ; will not take food. Urine clear, acid, sp. gr. 1015 ; no albumen or deposits. Has not menstruated since beginning of last pregnancy. Temperature 100.4. Several bruises on body, especially over right buttock. She was carried to bed and ordered beef-tea and some brandy. She did not sleep, and on the following day the choreic movements of the legs ceased, the legs became quite paralyzed and nearly devoid of common sensibility, the reflex action in them being absent. Bladder paralyzed, the urine having to be drawn off once, after which she could pass it. Muscles of eyelids and eyes quite under control. Not so the tongue, which she can scarcely put out at all, and then with a jerk to one side. Mental excite- ment abated, and speaks better. M. T. 99.4, E. T. 99.6, M. P. 80, E. P. 84. Takes liquid food ; eight ounces of wine, strong beef-tea, and extra diet. She improved slowly until on the 23d January (six days after admission) her state was as follows : " Chorea much less severe, complains of pain in the knees, evidently of a nervous kind, for pressure slowly and carefully made does not increase it. Common sensibility somewhat exaggerated in legs, and some power of voluntary movement has returned to them, but she has little reflex movement. Takes food well, bowels regular, no sweating, mentally confused, depressed, no memory, suspicious, will not believe a word said to her, wonders where she is and how she came here. M. T. 98.4, E. T. 99, M. P. 108, E. P. 100." 24:th Jan. To-day twitching of fingers only, except when she attempts any voluntary movements. More power of voluntary movement in left leg than right, which is almost paralyzed. Right knee slightly swollen. Reflex movement slight, and more active in left than right leg. Tongue twitches when put out, and goes towards right side. Temperature the same. She has hallucinations of sight and touch, saying that she sees an old woman coming behind her and eating her food, so that she cannot get any of it, and that one foot has been cut off. Is depressed, weeps and groans. 29th Jan. Has had a relapse ; chorea worse in left arm ; complains of pains in arms and legs. Complains of a burning feeling all over her. A large slough forming in right buttock where it had been bruised. She complains much of the pain of this. She still cannot tell correctly the place touched on her legs, but when pinched she screams. Requires to be fed with a spoon, shows an aversion to food, though she is evidently hungry. M. T. 100, E. T. 97, M. P. 116, E. P. 116. She has no affection of sight, and no sparks or motes before her eyes. KHEUMATIC INSANITY. 321 5th Feb. She now has so far recovered the power of her legs that she can stand. Chorea almost gone when she makes no voluntary move- ments. Mentally a mixture of stupor and depression, as before, and the hallucinations of sight and touch remain. M. T. 99.8, E. T. 101, M. P. 120, E. P. 120. She gradually improved, and her temperature fell until, on the 19th February, she was reported as having only very slight chorea in hands, but as still complaining of the pains in legs. Mentally she was still confused, but her memory was returning. M. T. 98.2, E. T. 98, M. P. 94, E. P. 100. She did not progress quite steadily, for on the 23d February her M. T. was 99.2, E. T. 99, M. P. 100, E. P. 108, and she was some days worse with the chorea than others ; but yet she was so far improved as to be, on the 15th March, out of bed nearly all day, able to walk, but the reflex action was much impaired in legs, and the left hand partially par- alyzed, and she had the sensation as if she did not feel the ground under her feet. Tongue now is simply unsteady when put out. Mentally less depressed, but still confused; very sceptical and much inclined to hide herself from observation; fancies she is watched. Temperature down to 97.8 in the morning. Is one hundred and twenty pounds in weight. Id April. " Believes now what she is told, and is almost rational ; but her right hand is swollen, though quite painless. Chorea rather worse, and she cannot sleep so well as usual." The sleeplessness in- creased, and the choreic movements began to trouble her exceedingly at night, and on the 4th her M. T. was 99.2, and her pulse 104 and weak. As an experiment I gave her twenty grains of chloral in the morning, which made her slightly drowsy, and quite stopped the choreic movements till the evening, when they came on again, and she could not sleep. I then gave her forty grains of chloral. She slept soundly ; the chorea ceased ; her temperature the next morning was 97.3, and the pulse 84 and stronger. Her mind had not been affected during this little aggrava- tion of the chorea. The swelling of the hand remained for a day or two longer, and then gradually disappeared. Still the reflex action in foot was diminished, and she complained of intense heat of hands. Wound on buttock healed up slowly. 22c? April. No chorea now except when she smiles ; she then grins and looks nervous in her movements. Sleeps and eats well. Industrious and rational. Has only gained two pounds in weight in a month. M. T. 98.4, E. T. 98, M. P. 96, E. P. 84. Her recollection of the coming on of the disease is imperfect, and she has no remembrance of the choreic movements beginning. Her mind must have been affected quite simultaneously with their appearance or before them. She does not even recollect the rheumatic pains going away. She says that she had no conscious feeling of weakness or ex- */ t J O haustion frjin the nursing before the rheumatism began. Her recollec- tion of events which occurred during the first month of her illness is very imperfect. 29th April. During the past week has gained five pounds in weight, and is now cheerful, rational, and says she feels perfectly well. Muscles 21 322 RHEUMATIC INSANITY. under her control. From that time her recovery was steady and rapid, till she was well in mind and body. Is any light thrown on the relations between rheumatism, chorea, and insanity, or on the connection between motor and psychical abnormality, by the case I have related? Was the rheumatism the true cause of the mental symptoms, of the chorea, or of both ? Were these abnormal affections of motion and the perverted psychical manifestations the result of an identical and simultaneous lesion affecting both the motor and mental ganglia ? Or was the one dependent on the other, secondary to it, or sympathetic with it ? Is it not evident that in this case we have a distinct form of insanity, a form about which much may be ascertained by a careful study of its relation to, and its correlation with, the motor symptoms ? It will be observed that nearly all the functions of the nervous system were here affected the nutrition, heat production, motion, sensation, reflex action, the special senses, the memory, and the intellec- tual processes all at the same time, and they recovered their normal action about the same time. I think it cannot be doubted by anyone that the rheumatism was the true cause both of the chorea and the insanity in this case. All the symptoms the coming on of the disease, the choreic movements, the paralysis of motor power, the deadening of reflex action of the legs, the hallucinations of sight, touch, and taste, the want of memory, the acute delirium with unconsciousness of anything going on around, succeeded by confusion of ideas, suspiciousness, and sluggishness of mind, the high temperature increased at night, the 'tendency to improvement in all the symptoms coincidently with the lowering of the temperature, and the slowness of the convalescence all .these things show that some lesion of the central nervous system existed. And when this is taken along with the fact that such a train of symptoms suddenly appeared in the course of an attack of rheumatism, that the symptoms of the articular rheuma- tism at once disappeared, while the fever did not do so, and that in this woman, when she was nearly well, rheumatic swelling of the knuckles of one hand appeared along with aggravated choreic movements, sleepless- ness, and an increase of temperature, we have very strong data, not only to conclude that rheumatism was the cause of the nervous and mental symptoms, but that here we have a true and typical example of a rheu- matic insanity, which must be classed by itself as a special form of mental disease a true pathological entity. As to how the nervous system was affected, may we not form a prob- able hypothesis ? We know how rheumatic disease, whatever it is, affects the other tissues. We know also something of the kind of lesions of the spinal cord which are needed to produce paraplegia and the total absence of the power of the reflex action, even if we do not know fully the pathology of chorea or of insanity. In regard to the motor affection of the legs, we saw that at first there was violent choreic movement, which was succeeded by complete paralysis of motion, no power of reflex move- ment, and greatly diminished common sensibility. As the power of motion returned, which was in the course of a few days, there were hyperaesthesia and a sensation of heat. Does not this sequence of phenomena indicate a serious but transitory interference with the func- KHEUMATIC INSANITY. 323 tions of the nerve-cells and fibres in the spinal cord, such as might be produced by slight rheumatic inflammation and infiltration of the con- nective tissue of the cord, causing pressure on the nerve elements ? If the nerve-cells or fibres had been themselves attacked with any inflam- matory affection, they would not have so soon regained their function. We know the rheumatic poison has a special tendency to affect the connective tissue. The rheumatic pains in the limbs are caused, we cannot doubt, largely by simple pressure on the small nerves. And if the cord was affected in this way, is it not probable that the same thing took place in the brain centres that minister to special sensation, and also in the mental portions of the organ ? The raised temperature and the strongly acid urine remained the same, whether the rheumatic inflamma- tion was in the joints or in the central nervous system. But when the inflammation had passed away, the effects were far longer visible in the delicate tissue of the nervous centres. In this case the insanity might be described as a metastatic one, if such a term were strictly applicable to the effects of a poison in the blood whose effects are first seen in one set of tissues, and then in another set. The slight relapse, when the hand and the spinal cord were both affected at the same time, showed, however, that the effects of the toxic agent need not be absolutely limited to one sort of tissue. If we believe this theory, that of embolism falls to the ground, as an explanation of the chorea of rheumatism with or without mental symptoms. There was no ascertainable trace of a tendency to heart disease in the case. The effects of embolism could not have so soon passed away, even if it is conceivable that it could have been universal in all parts of the brain and cord. It would seem that in such a lesion of the spinal cord as occurred in this case, the common sensibility was the last to be abolished and the first to come again ; then the voluntary motor power returned, then the reflex action, and, last of all, the power of the nerves which preside over nutri- tion. That the sensory and motor functions should have been less inter- fered with than the reflex action is what might have been expected, when we consider that the greater number of the nerve-fibres ministering to the two former merely pass through the cord, while the nerve-cells forming the ganglia which subserve the latter function, lie in the cord itself. The cord was evidently more affected than the brain. It was not until all the other functions were restored that the trophic function was restored, and the patient gained in weight rapidly. The slough that formed over the buttock from the bruise, and the slow healing of the wound, showed how much it was affected at first. In regard to the special senses, sight was first affected, and then taste, and they were restored in inverse order. Of the purely psychical functions, memory and the power of voluntary attention were first affected, then the coher- ence and balance of the mental powers were upset, and lastly the whole of the mental operations were merged in the acute delirium and utter incoherence present. Curiously, in all the patients laboring under this disease that I have seen, there were suspicions of those about them, and entire scepticism as to what they were told about the most simple matters during convalescence. Yet there was never in either of them any ten- dency to mistake the identity of anyone about them, and one of the very 324 RHEUMATIC INSANITY. first mental acts they performed correctly was to take notice of persons about them, and know them again when they saw them. The healthy elasticity of mind and enjoyment of life, which is the most certain proof that the brain is performing all its functions normally, was the last to return, and corresponded to the restoration of function of the centres of nutrition, and the commencement of a rapid increase in weight of the whole body. That was the first case of rheumatic insanity I ever met with, and it has been the best ; but I have met with many cases of the same type since. One had an attack of chorea in youth, previously suffered from, though without rheumatic symptoms. I had one woman in whom the disease was very severe, and ended in complete paraplegia and death in a few months. I found the cord to have undergone a destructive in- flammation and softening in all its columns pretty nearly throughout its entire length. The treatment of such cases is just the treatment of acute rheumatism, with the nursing and care suitable for a bad delirious kind of mania in addition. The prognosis is favorable in most cases. On the whole, the disease is rare. We may have a choreic insanity both in early youth the common time for chorea and in more advanced life without any acute rheumatic symptoms. The delirium is then, as Maudsley points out, of an inco- ordinated, jerky kind, like the muscular movements. Such a delirium is apt to come in bursts, and to pass away quickly. In the cases of chronic chorea the mental affection is often depression at first, then mania with impulsive acts of violence or suicide, and then dementia in the end. Some of these cases are very sad from the sufferings mental and physical the patients undergo through their involuntary jactitations. I had a man, J. G., who frequently had to be placed in a padded room to protect him from the bruisings he would otherwise have inflicted on himself. He at last literally wore himself out. One is justified in keeping such cases under the influence of chloral and the bromides to decrease their sufferings. Sleep in any form, and induced by any means, is to them a blessing, for it is the only time they are at rest and peace. In many forms of insanity there are choreiform movements that cannot be called ideo-motor. I had a case of general paralysis, J. H., in which the patient's left hand was always engaged in a rhythmical rubbing of his trousers with his thumb and forefinger. I have now a case, J. J., of chronic delusional mania, in which the fingers of one hand are rubbed over the thumb of the other so constantly in a rhythmical way that the cutis of both hands is quite horny ; and, like cases of ordinary chorea, if the patient is held still by muscular force, the subjective mental sensation is one of pain, which soon shows itself in outward acts. I had a case of chronic mania, J. K., a shoemaker, who, during all his waking hours, in church or at a dance, except when really shoemaking, went through the motor pantomime of pulling his threads through the leather. I have now a case of excited melancholia, J. L., a lady, who makes the most extraordinary choreiform faces and grimaces in a sort of automatic, un- thinking way. She says it is a relief to her to do so. This sort of move- GOUTY INSANITY. 325 ment is common among the insane, and I look on it as being in many of them closely allied to chorea. The treatment of all kinds of choreic insanity is, first, tonic and nutri- tive, and then anti-rheumatic. I have had one or two cases where arsenic worked wonders. I have had other cases where the bromides given as for epilepsy did good. Iron, too, and zinc, and the valerianates, are all good in some cases. Cold to the spine in certain cases temporarily stops the movements. In the Middle Ages there used to be wonderful epidemics of St. Vitus's dance, with mental symptoms that were certainly morbid, affecting at the same time thousands of persons by a kind of morbid sympathy and imita- tion. Mankind seems less subject to these strange imitative, uncon- trollable, mental-motor epidemics now than it was several hundreds of years ago. GOUTY OR PODAGROUS INSANITY. This is a rare disease in forms sufficiently marked to come under specialist treatment, or to be regarded as technically mental disease ; but mental phenomena due to gout are common enough, and have been described by all authors on the subject. Irritability, incapacity for mental exertion, and depression are the most common of these. Syden- ham gives a good description of them in his classic work on gout. " The body is not the only sufferer, and the dependent condition of the patient is not his worst misfortune. The mind suffers with the body, and which suffers most it is hard to say. So much do the mind and reason lose energy, as energy is lost by the body so susceptible and vacillating is the temper such a trouble is the patient to others as well as to himself that a fit of gout is a fit of bad temper." The above, no doubt, is the most common mental effect of gout, but it does not amount to mental disease. Deep melancholia is a common accompaniment of the gouty diathesis, especially about the climacteric and early part of the senile periods. I have had several cases of intense suicidal melancholia at this period of life in patients with a strong gouty heredity and gouty deposits, but who had not been subject to the regular acute attacks. I have one such case now, J. M., aged fifty-five, with a strongly gouty heredity and acquired syphilis, who was always more or less dyspeptic, and suffered from constipation. He always had marked psoriasis, and latterly gouty deposits on lobes of ears. Before he became affected in mind he fell off in flesh, his skin eruption disappeared, he became very costive, and a very dilated sigmoid flexure was found to exist. Sleeplessness and strong suicidal impulses, with delusions as to his trouble, were the chief charac- teristics of his depression, his reasoning power otherwise being good. Every kind of medical treatment anti-gouty, anti-syphilitic, soporific, sedative, and tonic was tried in vain. Nothing really seemed to do him good except feeding, with an excess of milk and eggs, sugar and fresh vege- tables, given at first by the nose-tube, and living out in the fresh air. He got fat and his sleep returned in about nine months, the acute misery dis- appearing, and I am not without hope of a recovery of an incomplete kind. He gained two stone in weight under treatment a great nutritive triumph 326 PHTHISICAL INSANITY. in such a subject. There are signs of slight degenerative tissue changes in him in the nerves or nervous centres, or both, evidenced by a partial paralysis of the ring and little fingers of the left hand, with wasting of the muscles. That of course I do not expect to disappear. Garrod de- scribes "gouty mania" as a very acute delirious affection, occurring in some patients immediately after the cessation of the acute joint affections. Along with the mania there are heat of head and fever. In one such case which he describes, all the mental symptoms passed off when one toe became affected in the ordinary way. This kind of acute gouty insanity either terminates quickly in recovery, or runs on to congestion and in- flammation of the membranes of the brain. PHTHISICAL INSANITY. An anaemic brain, from whatever cause, is always prone to disturbance of function. Lack of blood means imperfect nourishment. Where we have so vascular a tissue as the gray substance of the brain convolutions (almost half composed of capillaries), there the blood is needed in largest amount and richest quality if we are to have healthy and vigorous men- talization. Every one who has experienced any disease that has thinned and lessened the blood, has felt the difference in his mental power then as compared with health. The physiological effects of depriving the brain of part of its blood, or even of lowering the blood pressure down to a certain amount, are different in different cases to some extent. In this as in other ways in human beings, the strong and the weak hereditary qualities of a brain come out. One man merely has singing in his ears, a tendency to faintness, or a profound mental lassitude and paralysis of volition, amounting almost to torpor; those being probably the purely physiological mental results of a bloodless brain. Another man becomes intensely supersensitive and over-excitable, suffering torture from sounds and circumstances that in health would have been calmly borne ; another cannot sleep ; another has hallucinations of the senses ; another takes convulsions, long before that amount of blood is lost that necessarily causes convulsions ; and another becomes delirious, or is attacked with insanity. The same, or rather far greater differences of brain symptoms, result from the diseases and morbid conditions that cause or are specially accompanied by anaemia. The cachexiae, the blood-poisonings, and the diseases of nutrition in which blood is not made in sufficient quantity, may all be attended with danger to some brain functions, though certain brains seem to have the innate trophic energy to nourish their tissues and perform their functions on less blood than others. In those predisposed by heredity to disturbance or enfeeblement of the mental functions, it is the mind that suffers in conditions of bloodlessness. We are entitled to assume that the convolutions of such brains have less than the normal trophic and functional energy. After death, in such cases, the whole brain, but more especially the convolutions of the anterior lobes and the vertex, are often found disproportionately anaemic as compared with the other organs of the body ; and the brain is not only found anaemic, but manifestly wanting in normal consistence, in some cases atrophied to PHTHISICAL INSANITY. 327 some extent, and in others presenting an appearance closely resembling the first stage of necrosis from brain embolism. In all such cases its specific gravity is lessened. Chemical analysis of the brain has not as yet reached that point of certainty that it can tell us what constituents are specially wanting in such diseased conditions. In patients that have been insane, and had pulmonary consumption, I have seen the most marked brain anaemia, low brain specific gravity, irregular vascularity, and soft brain texture that I have met with, not being cases of " white softening " from embolism or other local cause of brain starvation. The frequent association of the depraved nutritive condition known as "scrofulous" with idiocy and congenital imbecility is well known and universally recognized by those who have had experience of such cases. The common occurrence of pulmonary phthisis as a cause of death among the insane had been long noted by those having charge of the older lunatic asylums. A special connection between the scrofulous and phthisical constitutions and the insane predisposition had been pointed out by Van der Kolk and others. The short attacks of delirium to which some phthisical patients are subject had been described by Morel. And that mild unreason, the spes phthisica, had been known from classic times. But any special manifestation of mental disorder directly connected with pulmonary consumption had not been described till in 1863 I did so, as the result of a very careful statistical inquiry into the matter. I was led to the conclusion that such a connection existed on clinical grounds as well as statistical ; l hence I called the form of mental disease Phthisical Insanity. This is not the place to combat the argu- ments that have been put forward against the existence of this mental disorder. No doubt consumption was startlingly more frequent as a cause of death among the inmates of the older asylums than in the modern institutions ; but still it is in all asylums for the insane between three and four times more common than in the general population at the same ages. In the Royal Edinburgh Asylum it has fallen almost to one- half in the past ten years under improved hygienic conditions compared with the period of 1842-1861. But that has nothing to do with the two per cent, of my patients that I classify on admission as phthisical insanity on account of their mental and bodily peculiarities, which I shall presently describe. No doubt brain anaemias of all kinds, and from whatever causes, are apt to produce mental conditions like phthisical insanity, and in some individual cases, I admit, quite indistinguishable from it. It is said that insanity is infrequent in hospitals for consumption. It may be that such mental disturbance as would be properly reckoned technical insanity is not common in such institutions, but, so far as I am aware, we have no statistics on that question. We have only one person in every twenty- one hundred of the general population becoming insane every year ; and if one in every thousand of the persons already phthisical became insane, that would not bulk largely in the mind of a physician to a hos- pital for consumption whose attention was not directed to the matter, though it would be an increase of insanity of one hundred per cent. 1 Journal of Mental Science, April, 1863. 328 PHTHISICAL INSANITY. But the great reason why insanity is not common in hospitals for consumption is simply that it usually appears before the lung symptoms of the phthisis, and the cases are sent to lunatic asylums instead. I have the satisfaction of knowing that many acute clinical observers have supported my conclusion that there is a phthisical insanity, Dr. Maudsley going the length of saying that he has seen many cases exhibiting a phthisical-mindedness not amounting to technical insanity, less in degree but the same in kind. No doubt my clinical experience of twenty years, since 1863, has modified to some extent some of my conclusions of that date. For instance, I do not now look on phthisical insanity as being so incurable a condition as I did then ; but I had not then had the experience of the working of modern hygienic ideas in asylums, or of the most recent modes of treating the insane therapeutically and morally. But, on the other hand, my experience has strengthened the conviction that a phthisical insanity exists, and in the typical cases is well marked in its characters, and that it is different in many essential points from any of the other forms of anaemic or diathetic insanities. It does not arise in asylums through any defects in their hygienic conditions or otherwise. The patients labor under it when they come into asylums. Its existence and amount have no fixed relationship to the death-rate from phthisis in the institution at all, for I find that while in the nineteen years 1842- 1861, the death-rate from this disease in the Royal Edinburgh Asylum was twenty-nine per cent., I estimated in 1863 from the symptoms of patients put down in the case-books that for the ten previous years about three per cent, of the admissions were cases of phthisical insanity ; and in the ten years 18731882, when the mortality from phthisis has only been fifteen per cent., I have, from my own personal knowledge of each case, diagnosed and recorded at the time two per cent, of those admitted as suffering from phthisical insanity. Those two things, there- fore, so liable to be confounded with each other, the general death-rate from phthisis and the number of cases of phthisical insanity admitted into an institution, must be put entirely apart. The general characters of phthisical insanity are such as might be expected to be found in persons of weak vitality. There is no acuteness of vigor about the symptoms of the disease. Looked at solely from the point of view of the mental symptoms present, some of the cases would be called mania of the mildly delusional, slightly demented type; more of them would be called melancholia, also of the mildly delusional type; and many of them would be called monomania of suspicion. It is a very striking fact in regard to the last, that nearly all pure cases of monomania of suspicion sooner or later die of phthisis. The symptom of a morbid mental suspicion runs through all the cases of phthisical insanity. Some- times, but not commonly, they have an acute stage at first, but .this is always short. Most frequently the disease begins by a gradual alteration of disposition, conduct, and feeling in the direction of morbid suspicion of those about the patient, a morbid fickleness of purpose, an unsocia- bility, an irritability, and an entire want of buoyancy and proper enjoy- ment of life. Along with this there are loss of weight, indigestion, intolerance of fat, want of enjoyment of food, perversion of taste in PHTHISICAL INSANITY. 329 regard to food, and a bad color of the skin. There may or there may not be any chest symptoms present; most frequently there are not. Then comes the acutest part of the attack, if there is such a stage in the case. The patient gets sleepless and mildly melancholic or maniacal, the bodily state running down all the time. The organic enfeeblement that characterizes the disease is often shown by refusal of food. The patient thinks he is being poisoned, this no doubt being the convolutional mis- interpretation of the pain and uneasiness of indigestion. In a way, he is often poisoned, for his food is badly digested and assimilated, and the subjective sensations accompanying this are not unlike some kinds of poisoning. After a little, the patient becomes irritable, sullen, unsociable, and suspicious, his state varying from time to time. The intellectual processes are not so much enfeebled as there is a disinclination to exercise them. There are occasional unaccountable little attacks of excitement. The patient is disinclined to amuse or employ himself. He looks on any attempt to persuade him to do so as persecution, and as being prompted by hostile motives. There is some depression, but no intense mental pain. The patient associates with no one, and the kindnesses of relatives merely call forth reproaches. If the patient lives long, he becomes more silent and apparently demented, but he can always be roused out of this for a short time. Complete typical dementia does not usually occur. If there is any tendency to periodicity, the remissions and aggravations are not regular or complete. Bodily he cannot be fattened, he looks sallow and haggard, his circulation is poor, his pulse weak, and anything like tone is entirely absent. There is no muscular energy, and a strong dis- inclination to exertion. The appetite is poor and capricious. Colds are taken very easily. The patients lose weight and are all round worse in cold weather. The temperature tends to be low until the lungs become affected, and then there is an insidious evening rise, which is perhaps the only sign of the presence of a bodily disease. In very many of the cases one-half the number, according to my experience the chest symptoms are at first latent even after the lungs have become markedly affected. There is no cough or spit or pain. I have often happened to notice that a patient laboring under phthisical insanity (and this applies to cases of dementia and many cases of acute insanity, too) was breathing a little more quickly than normal, or was looking more pinched, or was falling off his food, or his pulse was quicker and weaker than usual, or he had a hectic-looking spot on one cheek, or his skin felt hot; and on examining the chest in consequence of some such indication, I have found extensive broncho-pneumonia, or consolidation, or breaking up of the lung tissues. The progress of the lung disease varies much in different cases, in some being rapid and causing death in a few months, and others going on for years if the conditions, food, and hygiene are favorable. I have seen such cases in the very feverish stage before death, when the temperature rose over 102, rouse up wonderfully, and even cease to manifest the morbid suspicions, but such cases are exceptional. It would seem as if in these cases the high temperature and quickened circulation stimulated the anaemic and ill-nourished convolutions to increased and almost normal mental activity. 330 PHTHISICAL INSANITY. The following is an example of the disease : J. N., set. 43. Her previous history was not known very accurately, but this seems to have been the first attack of insanity ; it had not existed more than a few months. She resided in London, and came to Edinburgh to seek her son, who had been dead some time. This she had known before she became insane. No hereditary predisposition was known. She had been wandering about, and was troublesome, but not violent. On admission she was apathetic, and, when roused, suspicious-looking, not answering questions correctly or even intelligently, but showing her insanity much more by her peculiar expression of face and her conduct when spoken to than by her conversation. Hair dark, complexion dark. She is of the melancholic temperament. She was on admission thin and weak, but appeared before becoming insane to have enjoyed good bodily health on the whole. After being some months in the asylum, her mental state was as follows : "She has many delusions, which she only shows at times, and is not very consistent in her expression of them. She fancies that she is preg- nant, that the foetus is extrauterine, and that she will require to be operated upon. She is very suspicious, especially of her food, sometimes starving herself through fear of being poisoned. She also at times seems to imagine that she has much property that is being kept away from her. She is very idle, and cannot by any means be persuaded to employ her- self. At times, without any cause, she becomes abusive to those about her, and much excited. She remains thin and pale, but takes her food well, but has shown no clear symptoms of suffering from any actual lung disease. She is unsociable, takes no interest in her friends, does not want to get away from the asylum, or at least expresses no wish to do so. She gets excited for short periods of a few hours at times, and during these attacks of excitement all her symptoms are much worse." And in the course of two years her state was the following : She is now much thinner and weaker than she was, but no symptoms of any disease have manifested themselves, and she refuses to allow any examination to be made of her chest. She is more taciturn and less seldom abusive, except when she is spoken to or interfered with. She never speaks to anyone, except to ask for something she wants, resents being interfered with in any way, and treats all about her as if they were her enemies. When asked about her health she frequently becomes abusive, and seems to think some insult or harm is meant her. She is never pleasant by any possibility, and never thankful for any attention shown her. She distinguishes in no way those who are kind to her from those with whom she has nothing to do. At long intervals now she becomes excited, abusive to some one who has given no cause for such conduct, and she assigns no reason for such abuse. She remained mentally as described, but in bodily health became weaker, lost flesh, and did not take her food so well, but no cough or spit appeared till two months before her death, which occurred after she had been in the asylum five years. For two or three years before death she had been thin, pale, weak, capricious in her appetite, inclined to keep her bed, and evidently laboring under organic disease. She resisted an examination of her chest so very strongly that it was never thoroughly PHTHISICAL INSANITY. 331 made. There was never any diarrhoea, but all the other symptoms of phthisis were present in great severity for two months before death. POST-MORTEM EXAMINATION. The brain was atrophied, anaemic, and oedematous. The white substance composing and surrounding the fornix and septum lucidum was almost diffluent. The left lung was everywhere infiltrated with masses of tubercle, each tubercular spot soft in the centre. The cavities so formed were many of them evidently very old. The upper lobe of the right lung was in a similar condition. The rnesenteric glands were enlarged and tubercular. The mucous membrane of the caecum and ascending colon was ulcerated, thickened, and red. Commentary on such a case is almost superfluous after what I have said about phthisical insanity. A woman has a family, and lives till she is forty-three. She then becomes insane, never having very acute symp- toms, suspicion, irritability, unsociability, with causeless, unaccountable exacerbations, and a want of interest in anything, being the chief symp- toms. She is thin and in weak bodily health when she becomes insane, and although having good food and fresh air never gets stronger. She becomes weaker, paler, and thinner gradually, until she is exhausted and very weak, and then a severe cough and spit comes on two months before she dies. Can anyone doubt that in this case the insanity was contem- poraneous in its appearance with the preliminary symptoms of tubercu- losis, that the ordinary symptoms of the latter disease were obscured by the state of the brain, and that it was the tuberculosis, and not the insanity, that kept the patient thin and weak bodily ? And do not the mental symptoms resemble in some degree those of an exhausted man whose brain has been starved of a sufficient supply of nourishment by a disabled stomach, an exhaustive discharge, or unsound lungs? J. 0., 83t. 31, a joiner. Father had been insane. Had led a dissi- pated life at times. Had always made his living at his trade. Was married, and had a family. The first symptoms of insanity were noticed more than a year ago, and he was then sent to an asylum, but having apparently quite recovered, he was discharged. He was never quite well after this, however. He was unsettled, would not work at his trade with any one master for more than a few weeks at a time. He accused his wife of poisoning him, of conspiring against him, and of getting her relations also to plot against his life. His having been in an asylum at all he attributed entirely to their desire to get rid of him for their own purposes. On admission into the asylum he was generally quiet, reserved, and suspicious in look and manner, without showing much suspicion in his words. He was a man in average health, with a fair complexion, dark- brown hair, and a more than usually intelligent face. He was very reticent about his delusions. For some time after admission he wrought in the joiner's shop, but then began to fancy that his working there kept him in the asylum, and refused to work any longer. He became more unreserved in his expres- sions of dislike and suspicion of his wife and her relations. He might often be seen to exchange his own dish for that of his next neighbor at meals, when he could do so without attracting much attention. He looked as if he "knew all about it" when asked about this proceeding, 332 PHTHISICAL INSANITY. but would give no explanation of it. He evidently had strong prejudices against the head male attendant, and shook his head and laughed, and said, "You know very well," when asked why he disliked this man. At one time he became so well that his discharge from the asylum was con- templated. He had not been in the asylum six months till he had slight haemop- tysis, and when his chest was examined the presence of tubercular disease was indicated by dulness on percussion, and crepitation on auscultation at the apices of both lungs. He said, however, that he had often, before he came into the asylum, spat blood. Shortly afterwards, his condition was the following: "He now works in the joiner's shop only when he is almost obliged to do so. He often requires to be told that he will be carried out if he will not walk. He does not need to work hard, and is only asked to work at all for his own sake, because when he is employed in any way he is much happier and more content than when quite idle. He some- times abuses the head attendant in most unmeasured language. He imagines he is the heir to large estates, and is kept here a prisoner by his wife's relations to exclude him from his inheritance. No amount of persuasion will convince him that this is not the case. He is suspicious of almost everyone round him ; he tries to exchange the portion put before him at every meal for that of some one else. He is at times very irritable, and gets much excited. He took cod-liver oil for some days, but then imagined it was poisoned, and refused to take it on any account. He is constantly asking for changes of diet, and when he gets them he remains as dissatisfied as before. He is still pretty strong, and is in good condition; but complains, when at work, of shortness of breath. It is not for this that he refuses to work, however ; he imagines that it will be the means of keeping him longer here. His most common question to the reporter every day is, "When will this have an end?" referring to the conspiracy which he imagines is being formed against him. At times he is entirely reticent, merely shaking his head significantly when asked how he is " Oh, you know well enough, why ask me ?" A year after admission he was attacked with a cough and spit, and his difficulty of breathing became increased, and he was no longer asked to do any work. He got much worse mentally immediately after he was allowed to be quite idle. He could never be induced to take any kind of medicine for more than a day or two, and the extra diet and stimu- lants ordered for him were almost forced down his throat. The lung disease advanced rapidly. He became worse every week, while his sus- picions and irritability became the cause of more and more misery to him. He gasped reproaches against the medical officer, as he sat cough- ing and breathless, for giving him the medicines intended to relieve him. Everything that was done for him he imagined to be for a sinister purpose, everyone who was kind to him he suspected of being an enemy, and all the symptoms of his disease he believed to be caused by his food or medicine. All his symptoms were as severe, when they once had fairly commenced, as in ordinary cases of phthisis among the sane. To the last he retained his delusions unchanged. He died within PHTHISICAL INSANITY. 333 eighteen months from the time of his admission. He was much ex- hausted, but not quite emaciated, when he died. POST-MORTEM EXAMINATION. The brain was on the whole almost normal, except that the arachnoid was very milky, and the pia mater infiltrated with opaque serum, while the lining membranes of the ven- tricles were thickened and, in the anterior part of the lateral ventricles, covered with small granulations. The lungs were both almost entirely infiltrated with tubercle. This tubercle was very hard, however, except in some softened spots. It was intermixed with the fibrous pneumonic lung, and, as was seen from the appearance of some of the vomicse, as well as the consolidated fibrous lung, the organ had been affected for a long time. The cavities and the densest parts of the tubercular deposit in both lungs were at the bases. There was no ulceration of the caecum or colon. The mucous membrane of the stomach and duodenum was of a very dark color and very soft. This is a good example of those cases of monomania of suspicion, almost all of whom, according to my statistics, die of tuberculosis. The insanity was strongly hereditary. Such are the main and typical features of phthisical insanity, and the foregoing are good examples of the disease. Certain general questions arise in regard to it for answer. Are all cases where we have phthisis among the insane apt to be of the mental type I have described ? No, only those, in my opinion, who have had the well-known bodily symp- toms of the pretubercular stage of phthisis. The most marked cases are those with a hereditary tendency to both phthisis and insanity, or to the neuroses. It is surprising how often both diseases occur in different members of the same family. No physician in extensive practice but has met with very many such families. They are too frequent to be a mere coincidence. The constitutional weakness which tends to end in phthisis is, I have no doubt, akin in some degree, under some conditions, to that which tends to end in insanity. If one function of the brain is to govern the trophic processes of the body, and if that organ is strongly predisposed to go wrong in its mental functions in any case, it stands to reason that the law of the solidarity of action of the whole organ will come in, and that the nutritive processes will often be affected also, and the recuperative and resistive power lessened. Daily experience among the insane shows us that this is so. As I said when speaking of the nature and treatment of melancholia, thinness is its bodily essence and almost constant accompaniment, and fatness its natural cure. So in regard to that special tendency to depraved or weakened trophic energy that speedily tends to end in lung disease, if it is not cured it tends to affect the nutrition of the brain, and the result is phthisical insanity. Ascertainable hereditary predisposition to insanity exists in seven per cent, more of the cases of phthisical insanity than in the insane generally. Which disease begins first as an actuality ? The insanity in most cases, undoubtedly. In most instances it exists several years before any discoverable lung trouble appears, just as there are many persons who have all the premonitory symptoms of phthisis long before the lungs are affected. I am not now entering into the question of the different forms of phthisis, or the modes in which the lungs are affected, or into the 334 PHTHISICAL INSANITY. specific germ theory of tubercle. By the phthisis I speak of, I mean that typical form where there has been a marked constitutional tendency to malnutrition and lung disease, that form, in short, which is usually hereditary, and always has far more symptoms than the mere lung disease to characterize it. The mode and time at which the lungs are affected by actual disease are accidents due to special circumstances, such as exposure to cold. In regard to the question whether insanity is not sometimes cured by the advent of lung disease, I confess I have never seen any real instance of it. I have seen many cases where patients brightened up, and were less melancholic and far less torpid after the temperature rose through aggravation of lung disease, and I have seen this occur repeatedly in the same case as the inflammatory process became active. But the improve- ment was only apparent, and was always transitory. It simply resulted from the increased temperature and more active circulation in the brain. Any disease that produces those conditions will have the same effect. A very interesting question arises as to the effect of phthisis on the mental condition of sane persons. There is the universally recognized spes phthisica, and there is often also a mental brilliancy, short and fitful like the light of an ill-supplied lamp, and there are delirious, leth- argic, and confused times, in different cases. In very many there is a fancifulness, a causeless changing from hope to despondency, an inca- pacity for continuous thought, that seems to characterize this disease more than other chronic ailments. Doctors do not see these things so much, for at their visit the patients pick themselves up mentally ; but ask nurses and relatives who are with such persons all the time, and they will tell you of many small mental peculiarities of sane phthisical patients. In order to exhibit the results of my experience in regard to phthisical insanity for nine years 18741882 inclusive, in a statistical form, I have gone carefully through the case-books of the Royal Edinburgh Asylum. Each case was diagnosed as to its clinical mental type within the year of its admission. This is perhaps too soon in this form of insanity, for, as I mentioned, some of the patients have a regular maniacal and melancholic attack to begin with, of short duration, before they settle down. The general result was this : During those nine years there have been thirty- one hundred and forty-five admissions. Of these, eighty-five have been diagnosed as phthisical insanity. This is 3.7 per cent. ,of the cases admitted. Following out these eighty-five cases, I find . that twenty-six have been discharged recovered. This is a recovery rate of thirty per cent. The recovery rate in the asylum during the same period has been forty-six per cent. This would show, supposing my diagnosis to have been correct, that cases of phthisical insanity recover, but in much less proportion than the average of patients sent to the asylum, which include, it must be remembered, many general paralytics, paralytics, dements, and other cases, hopeless from the beginning. The recovery rate among the patients admitted with no recognizable organic brain disease, and who had been less than a year insane before admission, was at least seventy per cent. We may say, therefore, that the cases diagnosed as phthisical insanity recover in much less than half the proportion that cases of insanity uncomplicated with brain disease do. In order that this proper- PHTHISICAL INSANITY. 335 tion of phthisical insanity should recover, special treatment dietetic, moral, and medicinal is required to combat the depraved general and brain nutrition present. I next inquired into the death-rate from tubercular complaints among the eighty-five phthisically insane patients. Up to this time eighteen have died of phthisis, but it must be taken into account that in addition to the twenty-six who recovered there were thirty-two cases removed from the institution not recovered mentally, some of these being taken home to be nursed by their relations during their last illness to die, in short. Bnt more than the eighteen will die of phthisis, for those admitted in the recent years have not yet had time to develop the complaint, and some of them are now phthisical. The general result is that eighteen out of the twenty-seven who were not recovered or removed have already died of phthisis. I next examined into the general statistics of phthisis in the institution, quite apart from phthisical insanity, for the same period of nine years. Eighty-three cases died of this disease in that time. There having been altogether six hundred and thirteen deaths in the time, this was at the rate of 13.5 per cent., or one in seven. Of all the deaths from phthisis, therefore, 21.7 per cent., or just over one in five, had been originally diagnosed as phthisical insanity. Looking at the other clinical forms of insanity who died of phthisis, none of them approach in number the phthisical insanity. Seven cases of epileptic insanity died of phthisis and seven cases of general paralysis (though the large number of this disease who died of phthisis, I think, is much more than the average), and five cases of adolescent insanity, but beyond these no special variety was found in the phthisical list. In going over those patients who had died of phthisis I had an oppor- tunity of seeing a clinical fact in regard to the effect of the development of phthisis in one or two cases on a previously existing insanity. In such patients it often had the effect of producing a mental condition similar to the symptoms of phthisical insanity in patients who had not labored under such mental symptoms before. Such patients became suspicious, sullen, irritable, and unsocial, some of them being also melan- cholic. One young man, J. P., who had been a cheerful, active fellow, sociable, and constantly playing the piano and singing, became moody, suspicious, impulsive, and irritable just before his chest was found to be affected, and while he was getting thin, not taking his food, and looking ill. LECTURE XIV. UTERINE OR AMENORRHCEAL, OVARIAN, AND HYSTERICAL IN- SANITIESTHE INSANITY OF MASTURBATION UTERINE OR AMENORRHCEAL INSANITY. No doubt the influence of woman's great function of menstruation is considerable on her normal rnentalization. It has a psychology of its own, of which the main features generally are a slight irritability or tendency towards lack of mental inhibition just before the process com- mences each month, a slight diminution of energy or tendency to mental paralysis and depression during the first day or two of its continuance, and a very considerable excess of energizing power and excitation of feeling during the first week or ten days after it has entirely ceased, the last phase being coincident with woman's period of highest conceptive power and keenest generative nisus. As is well known to all physicians, many purely nervous derangements and diseases, such as neuralgia, migraine, epilepsy, and chorea, are apt to be aggravated at the menstrual periods or to begin then. There are often perversions of the great in- stincts and appetites then. In some women the social instincts are then partly suspended, and in others there are perversions of the appetites for food and drink. Dr. Halliday Groom has kindly given me the notes of two such cases. One young lady patient of his at every menstrual period pulls out and eats the bristles of the hair-brushes in her own room, and sometimes goes into other rooms for more brushes for the same purpose. He has another lady patient, married, set. 36, who, for fifteen years, has eaten at each menstrual period salt, dry oatmeal, and bits of sponge, and has been none the worse for this. I have met with (and what physician has not?) cases of women who had intense cravings for stimulants and narcotics at each menstrual period, and indulged those cravings, to their intense disgust and regret sometimes afterwards. Dr. Groom gives me the notes of a case where the craving was for malt liquors only. The regular and normal performance of the usual functions of the uterus and ovaries is of the highest importance to the mental soundness of the female. Disturbed menstruation is a constant danger to the mental stability of some women; nay, the occurrence of absolutely normal menstruation is attended with great risk in many unstable brains. The actual outbreak of mental disease, or of its worst paroxysms, is co- incident with the menstrual period in a very large number of women indeed. It does not follow from this, of course, that the menstruation caused the insanity in all such cases. The constant difficulty the physi- cian has is to know whether the disordered or suspended menstruation is a cause or a symptom. Nearly all the acute varieties of insanity disturb UTEKINE OB AMENORRH(EAL INSANITY. 337 or suspend menstruation in women while the acute symptoms last. I find that attendants on the insane do not expect menstruation to be regular, if present at all, in cases of acute mania or of intensely excited melancholia. I also find that among the women patients in an asylum, taking them throughout, chronic and acute, the occurrence of menstrua- tion is apt to cause an aggravation of the morbid mental symptoms present. The melancholies are more depressed, the maniacal more rest- less, the delusional more under the influence of their delusions in their conduct ; those subject to hallucinations have them more intensely, the impulsive cases are more uncontrollable, the cases of stupor more stupid, and the demented either more enfeebled or tending to be excited. In the chronic insane, whose home the asylum is, and its regulations and routine their rules of life, we frequently find the menstrual periods a time when their subjection to the asylum discipline is not so absolute as usual, and their conformity to the ways of its daily life is not so un- varying. Of course, there are a great many exceptions to this in the chronic insanity of women, to whom the menstrual period makes no difference whatever. Those are usually patients affected with quiet, mild dementia, who work hard and are in good bodily health. At times we see special directions taken by those menstrual aggravations of mental disease, such as an accentuation of the emotional perversions that exist, an excitation of the amatory feelings towards the opposite sex, a stimula- tion of the habit of masturbation, or the occurrence of stupor and con- fusion in the whole of the mental processes. The last (stupor) is ex- ceedingly apt to occur in young women during adolescence about their menstrual times. I have now a patient, J. Q., of nineteen, usually a bright, active girl, who, for about a week or ten days at her menstrual periods, becomes confused, stupid, and depressed her face and whole muscular movements showing an extreme hebetude and slowness. Some few melancholic patients get maniacal at the menstrual periods; and I have seen a case of acute mania cease to be excited, and become depressed and fearful during menstruation. Taking the mass of the more chronic and quiet cases of insanity, I find that menstruation is just about as regular as to time, and as normal in the amount of discharge lost, as among a similar number of average sane women. A very considerable number of female lunatics have the delusion that they are occasionally ravished by men at night, and this is usually more intense after menstruation. But apart from these general effects on all kinds of existing mental disease, of disordered or suspended menstruation, insanity in some few cases actually results de novo from this as an exciting or predisposing cause. Those cases may be conveniently termed uterine or amenorrhoeal insanity. Most of them, two-thirds at least, are melancholic in character, the mental symptoms following the amenorrhoea, and passing away when regular menstruation returns. The following is a typical case of this sort: J. R., set. 20, of a neu- rotic but not an insane heredity. Comes of an "excitable" family. Had gone from a country district and farm work to domestic service in a city, where, after a year or two, she fell off in general health, and ceased to menstruate. She at once became depressed, took morbid ond depressing 22 338 UTERINE OB AMENORRHOEAL INSANITY. views of religion, was forgetful, confused, and sleepless, and lost her ap- petite. She wept without cause; was very obstinate, misinterpreting the object of our giving her medicine, making her work, walk, and keep herself tidy. She said she should be out of the world and was not fit to live, but never attempted suicide. She was ordered, and made to take, iron and aloes, with much fresh air and fattening diet. She got worse at first, and hallucinations of hearing developed. She distinctly heard voices telling her she was the worst person alive. She would have re- fused food had she been allowed to do so. In about two months she began to improve in body and mind, especially in bodily looks and weight. For three months longer she remained depressed, and then menstruated after a series of hot baths and mustard to her feet. She brightened up from the first day of menstruation as if a cloud had been lifted off her mind, and she kept well ever after. In such a case I do not think it was the amenorrhoea alone which caused the melancholia. Both were in reality the result of a running down in health and vitality, but no doubt the mental symptoms were greatly aggravated by the suspended menstrual function. I do not think the melancholia would have been cured by a restoration of menstruation, had that been possible, before the blood had become richer and the nutri- tion improved. In fact, I have seen the coming on of the menses under these circumstances aggravate the mental symptoms, the case assuming during menstruation a maniacal form. The treatment of such cases should therefore be directed at first towards improving the general health more than towards restoring menstruation merely; at all events, until the nutrition of the body is improved. Then the usual means for re- storing the menstrual function should be resorted to, and when they are successful, or when, as most frequently happens, nature restores the function, the mental improvement is often as marked and immediate as in J. R.'s case. It will be observed that some amount of improvement took place in her mental state as the bodily nutrition improved before menstruation returned. The melancholic cases, of which this of J. R. is the type, nearly all recover, in my experience. Out of twenty-four of very typical form which we have had in the Royal Asylum in the past nine years, eighteen have recovered. About one-third of the amenorrhoeal cases were maniacal, with no melancholic tendency. Such cases were by no means so clearly con- nected with the absent menstruation as even the melancholic ones, nor did they show the same tendency to recover in mind coincidently with its restoration. In fact, I was by no means so sure of the same kind of direct connection between the amenorrhosa and the mental symptoms in most of them as in the melancholic cases. It is commonly supposed that the sudden suppression of menstruation in a young, full-blooded, healthy woman of nervous heredity, through chill or shock, is very liable to cause an outburst of acute delirious mania. Some authors speak of this as if it were one of the common causes of insanity. No doubt it occurs, but I have not met with more than two cases in all my experience. One was that of J. S., a girl of eighteen, stout, florid, and healthy, who got wet through and chilled while men- OVARIAN INSANITY. 339 struating. The flow suddenly stopped, and at once a fearful headache came on, with maniacal delirium, a temperature of 103, sleeplessness, and very great violence. A hot bath, with cold to the head, and with enormous doses of bromide of potassium, borax, and ammoniated tincture of valerian, frequently repeated, had the effect of diminishing the de- lirium and reducing the temperature. A condition of semi-stupor and confusion, inactivity and listlessness succeeded, and lasted for two months, when the usual mental health was regained, but it was several months before menstruation was restored. I should say that stupor is a more common mental result of suppressed menstruation in young women with a nervous heredity than acute mania. OVARIAN INSANITY "OLD MAID'S INSANITY." There is a somewhat ludicrous form of insanity that Dr. Skae called " Ovarian," or more familiarly and more correctly, I think, "Old Maid's Insanity." There is really no definite proof that the ovaries are either disturbed in function or diseased in structure in those cases, but it con- sists no doubt of a morbid transformation of the normal affectiveness of woman towards the opposite sex. The disease usually occurs in unpre- possessing old maids, often of a religious life, who have been severely virtuous in thought, word, and deed, and on whom nature, just before the climacteric, takes revenge for too severe a repression of all the mani- festations of sex, by arousing a grotesque and baseless passion for some casual acquaintance of the other sex whom the victim believes to be deeply in love with her, dying to marry her, or aflame with sexual passion towards her, or who has actually ravished her after having given her chloroform. Usually her clergyman is the subject of this false belief. Out of ten such cases which I can recall, seven have had clergymen as their supposed wooers or seducers. In no case was there the very slightest possible ground for the notion. In two cases the ladies had never even spoken to their supposed lovers. Certain gestures, or, as in one case, the contents of the agony columns of the newspapers, were sufficient proof to them of their beliefs. The annoyance to which un- fortunate men are subjected in this way is often extreme. Lately a lad^, J. T., now a patient of mine, went to a grocer's shop and ordered her supply of groceries in the name of a clerical acquaintance, saying she was his wife, telling the shopman to send the bill to him, and this as the cul- mination of a series of weekly letters to him of forty pages each. I have known grave accusations made to ecclesiastical authorities, and the be- ginnings of most injurious famas started by such insane women. Such patients are all of them between thirty-five and forty-three, and the reverse of sensuous in appearance. Some of them were most estimable ladies, Avhom it was impossible not to pity, the whole thing was so con- trary to the tenor of their lives, and so like a trick played on that higher being which they had always cultivated, by lower and more animal nature which they had sedulously repressed None of them recovered from this sort of delusion, but in two of the cases, as they passed into the senile period, and after the climacteric, the notion became so theoretical that they almost ceased to allude to it. 340 HYSTERICAL INSANITY. HYSTERICAL INSANITY. That form of mental disease which is complicated with some of the protean symptoms of hysteria should really be called ovarian insanity, if that name were used in any correct sense, for there is but little doubt that undue excitation or disturbance of the functions of the ovaries has more to do with hysteria than anything else. But perhaps it is more convenient to retain the name of hysterical insanity. Typical hysteria, pure and simple, always has a mental complication. The volition, or the feelings, or the morals, are always affected along with the purely bodily symptoms. But these mental symptoms, not forming the chief features of the disease, or not being of such a nature as to make the patient irre- sponsible or unmanageable, are not reckoned as being of the nature of technical insanity, at least among the rich. Among the poor, with no one to look after them, hysterical young women are often enough sent to asylums. And I have seen most admirable results from this. The principles of asylum life and treatment are the very best principles of treatment for hysteria too. To put the patient under control, to give her no harmful sympathy, to make her work and walk out regularly, to improve her bodily health, are always very good for a hysterical girl. We have had three cases of almost typical hystero-epilepsy, with a sui- cidal tendency in two of them, and general unmanageability at home in the third, in addition to the purely motor and other symptoms, sent to this asylum within the past few years, and I have not seen or heard of any home or hospital treatment so effective as the asylum treatment proved to be in these girls. 1 But such patients are rare in asylums. The usual type of case classified as hysterical insanity consists of mania or melancholia in a young woman with one or more of the following char- acteristics well marked, viz., a morbid ostentation of sexual and uterine symptoms, feigned bodily illness to attract attention and secure sym- pathy, marked erotic symptoms cloaked by something else, a morbid concentration of mind on the performance of the female functions, semi- volitional retention of urine, hysterical convulsions, a morbid wayward- ness, ostentatious and unreal attempts at suicide. The fasting girls, the girls with stigmata, those who see visions of the Saviour and the saints and receive special messages in that way, the girls who give birth to mice and frogs, and those who live on lime and hair, are all cases of this disease. Hysterical symptoms are exceedingly apt to occur in the insanities of puberty and adolescence, and along with those symptoms the habit of masturbation is common. It is sometimes difficult, therefore, to know whether to classify such cases as adolescent, hysterical, or masturbational insanity. All one can do is to ascertain if the hysterical symptoms are the most marked and prominent features of the case before we call it hysterical insanity. The following case of hysterical insanity fairly illustrates the general features of the disease. 1 Two of these are recorded by Mr. T. Inglis in the Edinburgh Medical Journal, December, 1878. HYSTERICAL INSANITY. 341 J. IL, set. 21, of a nervous and excitable temperament; habits correct. An aunt epileptic. Had on one occasion at home a mild attack of what must have been subacute maniacal excitement. The cause of the present attack, which has lasted for four days, was a fright which first produced ordinary hysterical symptoms, and then maniacal symptoms engrafted on them. She shouted and screamed, spoke of hearing God speaking to her, and would rush to the window to jump out. She imagined she was a most important person, attitudinized and did everything to attract at- tention to herself. Attention and sympathy were craved by her, and if she could not get them in one way she tried another. She refused her food, saying it was poisoned, but took it rather than be fed with the stomach-pump. She had menorrhagia, and was most minute and cir- cumstantial in the details as to her female health. She was tried with hyoscyamine, valerian, and mono-bromide of camphor with apparent benefit; but I considered the greatest improvement was produced in her case by discipline, work, open-air exercise, tonics, and good plain food in abundance. She improved at first, and once or twice relapsed, but in two months she recovered and was discharged. I do not like to keep hysterical cases too long in the asylum after convalescence as a general rule, for they sometimes get too fond of the place, preferring the dances,, amusements, and general liveliness of asylum life, even with its restric- tions, to the humdrum and hard work of poor homes. The following very characteristic letter of a maniacal hysterical girl, J. V., very well illustrates the trains of thought in such a case : l "Mr DEAR MAMMA. It is time that I leave to return home. I have been tremendously changed for the better. I think papa will be able to get me a com- mission under Garibaldi before long. There are three to whom I am especially in- debted one Mr C., the modeller, the other the doctor, a Eunuch, who modelled me at the fire, and attended on me and bathed me. He is I am sure a gentleman, a splendid doctor. Could not papa get him into a regiment abroad ? And there is the nurse. Could not papa get him any situation away from Morningside Asylum where I am at present ? I should like papa to come for me as soon as possible. Do you re- member the verse, " There are," &c. (12th verse 19th chapter of Matthew). About Eunuchs ? Then 1 beg to inform you that according to Scripture and my conscience, Jessy, your cook, is a man ; and Janet, the mad devil is a man ; and D. and H., boys who can have children. Aunt I. is a man, and yourself also, both made of men, and I am a boy, made of Dr C. and Dr Z. Mrs T. is a man, made of men. They are very ignorant on this subject here ; but as for me it is certain that at least the spirits have showed me, which Christ sent when I was under drugs ; they showed me this. I have at times since I came here passed the shadow of death, and therefore am authorised to speak in opposition to all men and women, gentlemen and ladies who oppose me. I am, I can I swear, as you want to know what sex I belong to, a mixture of a nymph and a half-man, half-woman, and a boy, and a dwarf, and a fairy. I know more than my fellow mortals, having expired eleven times before the time. I am, &c." Our statistics of hysterical insanity show a good proportion of re- coveries. In the nine years, 187482, there were thirty-four female patients so classified, and of those who were treated to the termination of their malady sixty per cent, recovered. 1 " Morisonian Lectures " for 1873, by Drs Skae and Clouston, Journal of Mental Science, vol. xix. p. 500. 342 THE INSANITY OF MASTURBATION. THE INSANITY OF MASTURBATION. The unnatural gratification of the sexual appetite through masturbation, it must be admitted, is very common among boys and lads. Especially, we believe, among lads of the educated classes, brought together in the somewhat artificial if not unnatural life of our public schools, does it prevail. I believe that the more healthy and more stolid country lad, the son of the farm laborer, is not so apt to indulge in this unnatural and disgusting practice as the son of the professional man, supposing each to be initiated in the same way. Boys are taught the habit, and begin to practise it, often long before they know or can know the real difference between sexual good and evil. But a healthy constituted lad in body, mind, and morals does not tend to come under its influence to any very hurtful extent. His natural organic repugnance to it strengthens as he grows up. If he is fortunate enough to have a home, or access to family life, his lower instincts are transformed and elevated into the normal social instincts, through the gratification of which they find a natural and pleasurable outlet. But the habit of masturbation, in certain other cases, acquires a power that is dominating and destructive to body and mind. The causes of this are, either an innate morbid strength of the reproductive instinct, or much more frequently an innate weakness of the controlling faculties, or of a lack of inherent brain stability, or of an incapacity of organic repugnance to what is unnatural. Such weaknesses are apt to occur in the children of neurotic families. From the beginning the habit is apt to take a deep hold of such youths, who practise it to the point of exhaustion of all nervous energy. Even when this occurs, and when in a healthy subject satiety would have caused disinclination and incompetence in the youths to whom I refer, the practice is not stopped. The weaker and more nervous he gets the more he indulges in the evil habit, till the point of absolute break-down of body and mind is reached. It seems to get pos- session of him like an evil spirit, and to dull and paralyze all his better feelings and his natural instincts. The heredity and temperament are no doubt the true explanation of the opposing statements that are con- fidently made, on the one hand, that this habit seldom does much per- manent harm, and, on the other, that it is the root of most of the evils of boyhood, and that it ruins the constitution for life of everyone who has ever indulged much in it. Both statements are so far true of boys of different constitutions and heredity. It is somewhat like drinking to excess ; many persons can do this at times without risk of dying the death of drunkards, but others cannot do so without that distinct risk. It is no doubt true that the restraint and management of the reproduc- tive instinct give most youths most trouble, and, as medical men, the priests of the body and the teachers of the truths of medico-psychology and physiology, we can often help them by our counsel and our knowl- edge. Unfortunately, our help is too seldom called in. We are about the only persons who can help a youth to strike the happy mean between blissful but dangerous ignorance and prurient suggestive knowledge. We THE INSANITY OF MASTURBATION. 343 are the only persons who can judge from the constitution of the particular individual how much he ought to know, and what risk he runs. As a complication and symptom of almost every form of insanity, the habit of masturbation is lamentably common. The melancholic, the maniacal, and the demented patients are all subject to its indulgence. The religious ecstatics who have direct intercourse with the Almighty, and the suicidal melancholies who have committed crimes beyond re- demption many of such patients of both sexes are masturbators. In fact it is, as it might be expected to be, a common sign of the loss of self- control which is the essence of mental disease. When practised to excess by the insane, it certainly tends to aggravate mental exaltation, to in- tensify depression, to lead directly towards mental enfeeblement, and to make impulsive tendencies more violent. It counteracts the effects of treatment, it induces relapses, and in some cases prevents the recovery of otherwise curable cases. These bad results are most frequently and clearly seen in the adolescent, hysterical, puerperal, epileptic, and con- genital forms of insanity, and, curiously enough, are not always absent in the climacteric and senile forms. I have seen a senile melancholic of seventy-five suffer intensely from the effects of the practice. In all these, however, it is one of many symptoms of mental disease. It is not the chief cause, nor is it the chief symptom present, and it does not color the cases so as to give them any distinct mental features. There is a form of mental disease, however, in which masturbation is the chief cause of the malady ; it is the chief symptom present, and it gives the whole case distinct features. This has been named the insanity of masturbation, and has several well-marked features. It conies on in youth ; it generally begins by an exaggerated and morbid self-feeling, or by a shallow, conceited introspection, or by a frothy and emotional re- ligious condition, or by a restless and unsettled state, with foolish hatch- ings of philanthropic schemes. There is no continuity or force in any train of thought or course of action. Then comes a melancholic stage of solitary habits, disinclination for company, especially that of the other sex, irritability, variableness of mood, hypochondriacal brooding, vacilla- tion, and perversion of feeling towards near relations. Suicide is often thought of, and oftener talked of, but masturbation makes most of its victims too cowardly to kill themselves. Then an acute attack follows, usually of a maniacal kind. This may end in recovery, or may run quickly into a dementia that is masturbational in character, being soli- tary, unsocial, and subject to impulses, sometimes homicidal a sort of masturbational hyperkinesia all these being incurable. With these mental symptoms there are usually well-marked bodily signs of the disease. The patient is thin, pale, and pasty, with a cold, clammy skin, a haggard face, and an eye that never looks straight at you. The patient has weakness in the back, pains in the head, palpita- tion of the heart, impaired sight, muscular relaxation, and sometimes spermatorrhoea. But for a complete record of the feelings and symptoms of the youthful masturbator one should rather go to those shameful quack advertisements put into the country newspapers than to medical books. They are there set forth at large, with just enough concealment to make them suggestive. That such abominable suggestions of evil should be 344 THE INSANITY OF MASTURBATION. allowed to be scattered broadcast into the families of decent people, is to me one of the standing marvels of our jurisprudence. They do and can do no good to anyone ; they aggravate the miseries of those who are suffering from the minor eifects of this vice by keeping them constantly before their minds ; they suggest evil thoughts to those who might be free from them, and they fatten the vilest of mankind. I verily believe, and I speak from some experience, that there are about as many people made insane by these advertisements and the pamphlets sent out by the advertisers, as by the habit of masturbation itself. No greater condemnation of the habit of masturbation can be imagined than the changed feelings towards the other sex which it produces. Nature there as elsewhere punishes the breaker of her laws. Such perver- sions of feeling are very interesting to the medico-psychologist. Instead of the true, healthy pleasure, intense as it is natural, of social and family intercourse, there comes a self-conscious bashfulness, a painful conflict between desire and repugnance, a suspicious constraint, and a guilty avoidance. The evil to him who evil thinks is seldom more marked than in the case of the masturbator. Any method through which this habit could be lessened among our rising generation would certainly do great good; life would be elevated in a large degree, self-respect would be increased, social intercourse would be sweetened and its pleasures inten- sified ; while the stings of self-accusation and remorse would be far fewer in after-life. The ordinary type of masturbational insanity is illustrated in many of its chief features in this case : J. W., set. 22, a young man of a naturally cheerful and frank disposi- tion and steady habits, and with a good family history so far as known. When an infant he was delicate, and was supposed to have been threatened with hydrocephalus, and he had convulsions during his first dentition. Those symptoms no doubt implied a neurotic heredity. Since then his health had been good up to his present malady. For years after puberty he indulged in the habit of masturbation to a great excess. He gradually fell oft' in looks and bodily vigor, and mentally he became changed. He got egotistical, hypochondriacal, changeable in his resolutions, fanciful, and unsocial. Those symptoms did not come on all at once, but took years fully to develop. They seemed to follow a diminution of nervous tone and general bodily strength. At last the mental depression stood out from all the other mental symptoms. It was hypochondriacal in character. He thought his sexual organs were "all gone," that his chest was "falling in;" he complained of pains in his back and in his head, and that his back was "very weak." When he was about twenty-two he made several feeble ineffectual attempts to commit suicide, both by hanging and strangulation. He was then sent to the asylum. He was pale, his muscles flabby, his skin moist and clammy, his tongue coated, his bowels costive, and his expression depressed and furtive. He never could look one in the face. Masturbators seldom can : but do not put down every insane person who cannot look you in the face as necessarily a masturbator. His genital organs were loose and flabby, and his testicles tender. He says he suffers from spermatorrhoea, but has now no natural sexual desire. Yet his mind runs on the subject, and it is one of the THE INSANITY OF MASTURBATION. 345 great sources of his mental depression that he has lost his virility. He thought himself very weak indeed, and that he could not get better. He said he would like to put an end to himself, and yet would not like to do so. He was ordered compound cod-liver oil emulsion with hypophosphites, strychnine, much milk diet, fresh air, cold sponging, and a little garden work. He was never done making attempts to strangle himself with his necktie. In about three months he was distinctly improved. His whole "tone" of mind, general nervous action, and of nutrition, was better. But he could scarcely be prevented from talking about himself and his ailments, imaginary and real. He wanted medical books to read about his case, and said he had bought and read all the quack literature on "nervous depression," etc., he could lay his hands on, which always made him worse. He ate and slept well, and, it was feared, continued his evil habit, but not to any great extent. In six months he had gained in weight, could employ himself more, and was much more cheerful. He was sent home half-cured, on the theory that he would there have more motives to rouse himself and go to work. That he did, and after a year he was pretty well. Here is the extract from a very instructive letter to me from J. X., a lad of twenty-two, who for two years had been hypochondriacal and un- settled, and alternately elevated and depressed in mind : " If I had come like a man to the point, and told the doctors what was the real matter with me (but in fact I really did not know myself till some time ago). I have committed masturbation for some years back, and sometimes as often as three times a day. I am sure I cannot explain myself nor give account of such conduct. Sometimes I felt so uneasy at my work that I would go to the W.C. to do it, and it seemed to give me ease, and then I would work like a hatter for a whole week till the sensation overpowered me again. I have been the most filthy scoundrel in existence. I did not know at that time what harm I was doing myself, although I knew I was doing something filthy and wrong, and many are the times I have made resolutions to put a stop to such conduct, and sometimes managed for a month, not more. Owing to my trade I fell in with lots of girls, but never cared much about speaking to them, owing, I believe, to me doing that filthy practice." He describes how he tried to have connection with a girl with whom he thought he had at last fallen in love, and that he failed, and that he was disgusted with himself and her. " This and other things, with my business not getting on, I was most determined to end my miserable career." He then described how he took laudanum, and how he felt afterwards. " I hope for my father's sake you will give me your advice, not for my sake, for I am not worth taking notice of. Some time ago, when I was wondering if there was any seed left in me at all, I committed masturbation, but had to do it for a considerable time, and after some did come it was dull in the color and scanty, and instead of a pleasant sensation it pained me." After a month or two this lad's de- pression passed off, and as his bodily health improved he became ex- citable, restless, egotistical, and irritable. This lasted for a time, and he then appeared to get quite well in mind and body. I have known many instances of the habit of masturbation being taken to without any teaching, and in some cases at incredibly early ages. I 346 THE INSANITY OF MASTURBATION. have now a patient, J. Y., who is always nervous, diffident, unable to earn his own livelihood, tending to be depressed and suicidal at times, and egotistically irritable, conceited, and impracticable. At other times, every now and then, he gets so depressed that he has to be sent into the asylum, or comes into it of his own accord. This man has frequently assured me, when at his best mentally, that he acquired the habit when he was six years of age, that no one taught him, that almost ever since it has been his bane and curse, that he knows as well as anyone how wrong it is to practise it, and that it does him infinite harm in body and mind ; and he says that at times his mind is filled with disgust at the filthy nature of the practice, and despair at the hold it has acquired over him. Yet, in spite of all this, he cannot stop it, the morbid fascination over his mind is so powerful. He describes it as like a fate that he must yield to, an involuntary act over which his will seems to have no control, though the practice of it is at times painful and not pleasurable. Yet I never saw any case in which suitable treatment, control, fresh air, hard work in the garden, and suitable food, had so good an effect. After two or three months he became another man, lost to a great extent his hang- dog look, his depression, his suspicions, and hypochondriacal notions, got fresher and fatter, and had less marked inclination towards his evil habit. But it has unmanned him, and made him quite unfit for facing the world. So anxious was he to be cured, that he has had himself castrated lately. This has stopped the tendency to masturbation, but mentally some de- pression and "nervousness" remain. There is no doubt that the act of masturbation is often not only done involuntarily and contrary to* every inclination of the will, but it may also be unconsciously done. I have seen it done in the unconscious period immediately after an epileptic fit ; and in the unconscious stages of acute mania and excited melancholia it is most common. Many of the cases do not recover. I have many patients in the asylum, of which this is a type: K. A., get. 37. Began to masturbate at fifteen, and has continued the practice to excess ever since. He became so insane as to require to be sent to the asylum at twenty, after a year or two of restless egotism and selfish hypochondriasis, varied by spurts of equally selfish emotional religionism at home. He at first could reason, read, and occupy himself a little, but as the habit has gone on his mental power has gradually weakened, his social instincts have become extin- guished, his self-respect and all his sense of decency have become utterly lost. He is now a slouching, untidy-looking fellow, with a hang-dog look, who can never be got to look you in the face, who never reads or speaks to anyone, cares nothing for his relatives, has no energy, looks pale, red-nosed, and pinched. And yet he is not quite demented in the ordinary sense. He is coherent, and you find his memory is not gone when you talk to him. The general principles of treatment of masturbational insanity unques- tionably are to brace up the youth bodily, mentally, and morally. In the first place, the diet should be unstirnulating and fattening. It is strange that the physiological inductions of the old Catholic Church as to the dietetic management of the nisus generativus and its volitional control have been so neglected by modern physicians, founded as they THE INSANITY OF MASTURBATION. 347 were on the experiences of the terrific conflict with nature that was implied in the early Christian theory that sexual desire was more or less of the devil, and should be eradicated and not merely regulated by all men who wished to attain a high religious ideal ; and in the later rule of priestly celibacy. My own belief is that the Catholic view of repression and eradication being, for the sake of argument, granted, almost every rule of the church as to food and fasting, and every practice of the mon- astic orders, and every conventual regulation, is a correct physiological principle. Translated from religious into physiological language, they may be summed up thus Strengthen the power of inhibition bodily and mental. Practise the habit of mental concentration and abstraction from certain lines of thought. Cultivate enthusiasm about ideals. Find ideal outlets for the affective and social faculties other than sexual choices. Sleep only under such conditions and so long as to recuperate lost energy and tissue, and not to accumulate energy that there might be a difficulty in getting rid of short of sexually. Eat only non-stimulating and fat- tening food, and that in moderation, with periodic abstentions to use up spare material in the body. Avoid flesh, as the incarnation of rampant, uncontrollable force, sexual and otherwise. Be much in the open air % and work hard. Finally, so fill up and systematize the time that none is left for day-dreaming. Now, such are undoubtedly the proper rules with which to treat the habit of masturbation and its mental and bodily effects. If we add to those the medical means of cold baths, tonics, games, family life, and a course of bromide of potassium, our resources are pretty nearly exhausted. I would certainly avoid local treatment or mechanical appliances as a general rule. It is no doubt possible to make the organs of generation so sore that excitation of them becomes im- possible ; and if the patient's imagination has disappeared through his dementia, this rest from constant nervous exhaustion may be taken advantage of to feed him up and get him into habits of working, and into a comfortable dementia. That is a good thing, but it only applies, in my experience, to those whose mental power is already gone. For the masturbator whose mental energy is still there to some extent, or only temporarily suspended, such mechanical expedients and obviators of present indulgence only concentrate the attention on the function, and cause desires that are intense in proportion to the present impossibility of gratifying them. Do not recommend marriage as a remedy. It is a most dangerous experiment. It is apt to be followed by sexual repug- nance in a short time, and the last state is worse than the first, two persons' happiness being destroyed instead of one. There have been forty-six cases that I have diagnosed as masturbational insanity sent to the Royal Edinburgh Asylum during the past nine years, and of these sixteen, or twenty-five per cent., have made good recoveries, doing their work in life well afterwards. Some of the cases I have been consulted about out of the asylum, and some of those I have had under my care in it, are now occupying responsible positions and doing first-rate work in the world. Some are the fathers of families. There is no ground whatever for such an unfavorable prognosis in any case I have met with as some medical men in the habit of giving, and there is no sort of ground for thinking there is any special risk of relapse, or any special 348 THE INSANITY OF MASTURBATION. form of nervousness, that will necessarily stick to a masturbator all his life. Eighteen more of the cases left the asylum more or less improved, while twelve still remain there hopeless, incurable, and degraded. One warning I have to give before I have done with this disagreeable subject. It is this : not to believe all the melancholic patients who attribute their bad symptoms to the former practice of this vice in youth. This is a common self-accusation. In most instances it is a mere delu- sion, like so many other melancholic delusions, founded on a morbid exaggeration of the consequences of departures from strict rectitude. It just amounts to the same thing, psychologically, as such common melan- cholic fancies that the loss of control over the temper, and calling a friend a bad name ten years ago is an unpardonable sin, that not going to church on a certain Sunday will be punished by eternal damnation, or that a gonorrhoea in youth has so polluted the blood that all the offspring are diseased, and that death must ensue. The real significance of mas- turbation in each case must be carefully inquired into, and the facts ascertained before a conclusion as to its effects is formed. LECTURE XV. PUEKPEKAL INSANITY LACTATIONAL INSANITY THE INSANITY OF PKEGNANCY. CHILDBIRTH, nursing, and pregnancy in women are liable to act as the exciting causes of attacks of mental disease. In importance and frequency they stand in the order in which I have placed them. For many reasons it is especially necessary that the general practitioner of medicine should be well acquainted with these forms of insanity, for they all occur at a time when he is apt to be attending the patient for other reasons, they all can under favorable circumstances be treated at home in many individual cases, and it is well so to treat them when possible. They are all very curable forms of mental disease, and, when cured, they are not apt to leave any traces of mental weakness or obliquity behind. The patients can resume their work and places in the family and society, and be as if they had never been ill. The three forms, though having much in commom, yet differ in so many respects that I must take them separately. The advantage and the practical necessity of classifying mental diseases in other ways than according to the mental symptoms present, are especially seen in these three forms of mental disease. To know that a case is one that has begun after recent childbirth is to know far more about it than to know it as mania or melancholia for treatment and for prognosis. There is no practical physician but will admit this. PUERPERAL INSANITY. I do not know any event that can occur in a family, short of death, that is so great a shock to all who have to do with it, as for a new-made mother of a first-born child to become suddenly maniacal, and require to be sent to an asylum. One of the most joyous times of life is made full of fearful anxiety, and the strongest affection on earth is then often suddenly converted by disease into an antipathy ; for the mother not only "forgets her sucking child," but often becomes dangerous to its life. And few things are more pleasant than to see the restoration of the mother back to all that makes her life worth having. Puerperal insanity is technically limited to the mental disease that occurs within the first six weeks after confinement. By far the majority of the cases, and by far the most acute and characteristic cases, occur within the first fortnight. It is a very common form of mental disease, for five per cent, of all the cases of insanity among women are puerperal, and I think that it is a low estimate that one in every four hundred 350 PUERPERAL INSANITY. labors is followed by it. In one-half of the patients the disease begins within the first week after confinement, and in three-fourths of them within the first fortnight. In regard to the cause of the disease, therefore, it is definite and clear. The accompaniments of childbirth produce it. The great physiological cataclysm itself, the pains of labor, the excitement mental and bodily, the exhaustion, the loss of blood, the open bloodvessels liable to absorb every septic particle, the sudden diversion of the stream of vital energy from the womb to the mammae, these together or separately are the causes that, acting on an unstable brain hereditarily, set up one of the most violent mental storms that the physician has ever to treat. And it comes on very suddenly in most cases. The mother looks self- absorbed and dull. She does not take such notice of the baby as is usual, or such interest in what is going on. She does not answer questions readily. She does not eat, and she does not sleep at night. Xext morning she is restless. Her eyes are brilliant. She seems to have no sense of exhaustion. She expresses foolish fancies, such as that she is poisoned, that there is some one under the bed. She takes a violent dislike to the doctor, or the nurse, or the child. She begins to chatter all the time, and her talk becomes less and less connected. She is erotic, joyous, scolding, and perfectly incoherent all within a few hours. She gets violent, and needs to be held in bed ; impulsively and without set intent she attempts suicide, or tries to kill her baby, or to throw herself out of the window. She seems as if she had a supernatural strength. Yet when you feel her pulse it is weak and thready, her face looks haggard, her temperature has risen to 100 or more, her womb is tender on pressure over the abdomen, and she will not look at food. Her lochia have first become somewhat offensive and then stopped. Her skin is moist and clammy. She soon ceases to know those about her, calls her friends by other names, and strangers by the names of her friends. Her lips and tongue show signs of getting dry. If she is poor or cannot get plenty of nursing or medical attendance, she must be sent to the nearest asylum, and the sooner the better, for she needs all that the asylum can do for her. She needs to be fed at once, nolens volens (by means of the rubber nose-tube if she will not take it otherwise), with plenty of milk and eggs, and soups, and wine, and this needs to be repeated every hour or two. Let her alone, and she dies or becomes demented. Narcotize her with morphia, and her secretions dry, her tongue gets furred and hard, and her antipathy to food is doubled. But nurse and feed her well by night and day, striking the happy mean between undue restraint and too great activity, get her out for a little in the open air in a day or two, keep up the attendance, and in a week she will show a little sign of mental coherence, in a fortnight her appetite will have returned, her pulse will be stronger, her temperature will have fallen to normal, and she will walk out herself without tearing her clothes or throwing herself about. In a month she will be knitting a stocking, and will know her friends when they come to see her. Within three months she is well a joyous mother, in her right mind, clasping her child, the whole of the disturbed mental period seeming like a dream to her, that is very soon altogether forgotten in her new duties and delights. Although puerperal insanity is more frequent in first than in subsequent PUERPERAL INSANITY. 351 confinements, yet it is common enough in the latter, and I have known a woman, K. B., who had six attacks of puerperal insanity, having one after the birth of each child she had, and she recovered from them all. But this is the exception. The woman that cannot have a baby without having also puerperal insanity, and who persists in having babies, usually remains more or less permanently affected after the third or fourth attack. The ordinary causes of mental disease contribute as predisposing causes towards puerperal insanity. Poverty and want of proper attendance during childbirth, and having to get out of bed and to work too soon, I have seen bring it on. The shame and mental distress usually attending the birth of illegitimate children make it twice as common then as after the birth of legitimate children. I have several times seen a sudden mental shock act as the proximate cause of the disease in women who seemed to be doing well in childbed. I once saw the news of the death of the patient's father send a woman, in the second week after confinement, into acute mania, within a few hours. But such moral or other causes are not at all necessary to produce the disease, over and above the puerperal condition. In by far the majority of the cases there is no other cause. It occurs in ladies with every comfort and attendance as well as among the poor. Most of the recoveries from puerperal insanity are gradual ones. We do not commonly find those sudden wakenings up from an acute delirious condition into coherence, self-control, and sanity that we sometimes see in other forms of mental disease. That is, in my opinion, one of the reasons why the recoveries are apt to be complete and permanent. I do not like very sudden recoveries in any form of mental disease, because they are not so apt to be permanent, and they indicate an essentially unstable dynamical condition of the convolutions. I am never quite satisfied about the recovery of a puerperal case until the woman gets stout and strong, and until her menstruation has returned and become regular. The following is a typical case of puerperal insanity of the acute but not delirious kind: K. C., set. 19, a hard-working domestic servant, with no known heredity to the neuroses. Though she came of a " respectable" family, she had an illegitimate child born in the Maternity Hospital. Her labor was not specially severe, and she did well for three days. Then, without any new cause, she got dull and took no notice of her child or of anything else; in a few hours she began to laugh hysterically, then she got more excited, restless, noisy, and talked incoherently about religious matters. She did not sleep, and in four days she had to be sent to the asylum. On admission she was much excited and greatly exalted in mind. She mistook the identity of everyone near her. She sung on at the pitch of her voice in a rhyming way, putting her delusions and con- versation Avith herself into rhyme. Her ideas and currents of thought were always changing. She looked pale. Her pulse was weak, and her temperature was 98.2. She did not sleep for the first week at all. She was restless, singing, loquacious, and delusional all that time. She was put on all sorts of very nourishing food, especially custards of milk and eggs, and she was taken out into the open air for a short time each day after the first two days. She began to sleep in a week, and after that slept more or less regularly. She continued restless,- good-natured, and 352 PUEEPEEAL INSANITY. talkative, destructive to her clothes at times, full of boisterous, half inco- herent fun, and unable to settle to do any work for two months. She gained in weight all that time, eating well and spending much time in the open air. Then she began to work, was put to rough scrubbing and laundry work, so getting rid of her excessive muscular energy. In three months she was fattening, quieting, and working hard. In four months after admission she was stout, sensible, and well in mind and body, menstruation having begun, and she was then sent back to her situation, which had been kept open for her in consideration of her previous good conduct. Some of the very acute cases with a high temperature and most un- favorable symptoms make good recoveries, if proper treatment is adopted soon enough, as in this case: K. D., set. 27. A married woman of correct habits, with no known heredity to insanity; her first child. Her labor was natural. Things went on well for a week ; then, without apparent cause, she began to complain of headache and costiveness. She got restless and sleepless, then next day she became foolishly talkative and erotic, and neglected the child. The lochia and milk stopped. She refused food absolutely, getting worse day by day, and becoming weaker fast. She wanted a razor to cut her throat, and threw a tumbler at her husband, but was not very suicidal or dangerous. In two or three days, she was absolutely delirious and incoherent, but was not sent to the asylum till seven days after the mental symptoms appeared. On admission, she was greatly excited, shut her eyes tightly, singing and swearing, and using the most obscene language continuously. She seemed to imagine she was in hell and surrounded by devils at one time, and she had exalted fancies at other times. She did not sleep at night, and with the utmost difficulty was got to take some little liquid nourishment. Her temperature was found to be 100. Her pulse was very thready, her skin clammy. She was constantly jerking and throwing her limbs about, her tongue tending to be dry, and her general bodily condition one of great exhaustion. She got ten grains of ohloral and slept three hours the first night. Next day she was fed by the nose-tube with a custard containing three eggs, one pint of milk and cream, some strong beef-tea, four ounces of port wine, and five grains of quinine. This acted as a soporific, and she slept well most of the afternoon. After awaking, she was less excited, but confused in mind. This mode of feeding was continued twice a day. On the fourth evening after admission her temperature was 103.8, but mentally she seemed to have a lucid interval, being rational, and she then took her food. Some fetid lochial discharge made its appearance at this time. Weak carbolic vaginal syringing was used. On the sixth day she be- came again acutely maniacal, with a morning temperature of 101.4, an evening temperature of 102.8, and she had to be fed with the tube. On the eighth day she was sleepy and quiet, took her food, and after two days of confusion of mind got quite sane, and remained so, remembering nothing of what had taken place during her illness. I allowed her friends to remove her on the twenty-first day, she having a good home, where her bodily strength could be got up as well as in the asylum, and she has kept well ever since. PUERPERAL INSANITY. 353 Puerperal insanity is that form of mental disease in which we are least apt to have relapses after the patients have once fairly become convales- cent; and I have less hesitation in letting relations remove them from the asylum at an early period, if they have good homes and attendance, than in any other form. In this case of K. D., I looked on the feeding at once as having saved her life. The immediate sedative and soporific effects of filling the stomach with food and stimulants were most striking, and I very often see this. There is no doubt whatever in my mind that alcoholic stimulants along with food are of the utmost service in many cases of puerperal insanity, their good effects being more immediate, in my opinion, than in any other form of mental disease. In the case of patients being attacked with puerperal insanity who have good homes, especially if they are in the outskirts of a town or in the country, and can get constant medical attendance and good trained nursing, they may often be treated at home. I lately attended a lady in consultation, K. E., who, within ten days after confinement, became sleepless and restless, took antipathies to her doctor, monthly nurse, and child, mistook the identities of all those about her, calling me by the name of an old friend, Avho had a temperature of 101, with slight uterine tenderness and absolute refusal of food, being most troublesome and difficult to manage. I sent a first-rate attendant from the asylum in addition to the ordinary nurse and servants, and she was fed, controlled, nursed, taken out, and got through her attack in about six weeks, just as well as if she had been sent to an asylum. But the strain and responsi- bility on relations, attendants, and nurses were no doubt most severe, and they were nearly exhausted by the time the patient had recovered. The following case had a melancholic character throughout, though acute -and curable: K. F., set. 23. No heredity ascertained. Had been a strong healthy young woman, and had had one child previously eighteen months ago. This child took a convulsive attack within a week after her second confinement, and the fright and shock of this seemed at once to upset her mentally, for she was within a few hours afterwards incoherent and maniacal. She was put under chloroform, and got morphia in quan- tities, and was kept under the chloroform almost continuously for a week. This deadening of the brain functions did not cure the maniacal condi- tion ; whenever she awoke she was as bad as ever. But next week she was almost sensible. After that the acutely maniacal condition returned, and after a week of it she was sent to the asylum. She was then intensely depressed, looking afraid of something going to happen to her, imagining that something was in the bed. Her memory was gone. She did not know her husband, and mistook the identity of the people about her. She had hallucinations of hearing. Her pulse was 120, feeble and intermittent. Her temperature 104.2. Altogether she was very ex- hausted. She was fed hourly with custards and sherry in large quantity. On the second day after admission, her temperature suddenly sunk to 97.2 and her pulse to 78, and this was coincident with the appearance of a profuse bloody lochial discharge. Mentally she was also much improved, though not quite rational. Towards evening she became rest- less, and had the hallucinations of hearing again, though her temperature was only 98. She did not sleep, and was very depressed and restless 23 354 PUERPERAL INSANITY. next day, saying she was a great prodigal and a sinner, but took food voluntarily, though needing forcing to take enough. The temperature never again rose above 100. She frequently showed the morbid brain tendency of repeating a word said in her hearing over and over again, e.g., Zachariah-iah-iah-iah Zach-ire." She was well fed and nursed, and usually slept about three or four hours a night. In a week she was able to be taken out into the garden, and slept much better after this. In ten days, had small abscesses forming round one or two of her finger- nails. This "critical" symptom not at all uncommon in cases of recent maniacal and melancholic condition seemed to do her general brain condition good. She passed in a month into a quiet, lethargic, rather suspicious state, and still depressed, but with no intense mental pain, and no delusions expressed. Then she got into the state that is very common before recovery in patients in asylums one of discontent, of increasing instant desire to "go home," inability to understand that anything has been wrong, or that further treatment away from home is required. I have ten times the trouble with my patients and sometimes with their friends in this stage, for the chief symptoms of the disease have passed off, and the patients seem rational. She was dull and suspicious in the mornings, and quite well sometimes in the evenings. All this time she was gaining in flesh and color and strength, walking much, drinking much milk, and being encouraged to employ herself in the house. In three months she was sent to our sea-side house, and had sea air and sea bathing, both of which did her much good. By that time she had gained a stone in weight. In four months, she menstruated for the first time, the last cloud of depression passed away, and she was sent home quite well. The following is a typical case of puerperal insanity dying of sep- ticaemia, or a case, more probably, of puerperal fever with maniacal symptoms : K. G., set. 23, of a cheerful disposition and good habits. Sister and aunt have been insane. Has been married between four and five years, and has had four children in that time, all born dead, all the labors being difficult on account of a deformed pelvis. Had been weak during all the last pregnancy, and had pains in the head for two months before delivery. Premature labor was induced about the seventh month, with a view of saving the child and making her labor more easy than the others had been. In a day or two after delivery she began to see faces on the wall, to think that the chairs were alive, and that people were whispering slanders about her. She did not sleep, and would not take food. She got rapidly worse, becoming quite maniacal, delirious, and unmanageable. She imagined poison was put into her food, and wanted to rush away from home. On admission she exhibited a combination of intense ex- citement in paroxysms, during which she required three attendants to hold her in bed, with extreme prostration and weakness between. Her pulse was thready and 156, temperature 102, respirations 60. There was an anxious look, with great pallor of countenance, when not excited. There was evidence of congestion of both lungs, with pneumonia at the bases. There was no evidence of tenderness on pressure over uterus. No lochial discharge. She was fed with brandy and custards on admis- sion, and every hour thereafter, getting ten grains of quinine every two PUERPERAL INSANITY. 355 hours for the first eight hours. In spite of all that could be done she sank on the sixth day, the temperature having kept up all the time to between 101.4 and 103.8, the lung symptoms getting worse, and the intense delirious excitement coming on once or twice every day except the last. On post-mortem examination I found the brain intensely congested, and the lungs pleuritic, very congested, and almost hepatized at bases. But the chief seat of disease Avas in and round the womb. There was a thin layer of pus on its peritoneal surface. There was a small abscess in the right ovary, which seemed to occupy the position of a recent corpus luteum. The uterus was large and flabby (about six inches by three inches), its substance on section containing much purulent matter all through it, but especially towards the mucous membrane in the fundus. The mucous membrane was thickened and covered with yellowish purulent matter, and some of the remains of the placenta were adherent. One of the uterine veins on the right side, for about four inches in its course towards the vena cava, was unusually enlarged, looking like a bit of very small intestine, its coat thickened, and its lumen filled with thick grumous pus. It is difficult to say whether this was a case of "puerperal insanity" with septicaemia, or "puerperal fever" with maniacal delirium. I think the latter is the more correct description. It was, I think, evident from the post-mortem appearances that there was septicsemic puerperal fever from the beginning, and this occurring in a weakened anaemic brain pre- disposed to insanity no doubt produced the maniacal symptoms. I had this year a case of puerperal insanity, K. H., dying in four days of meningitis, which came on twelve days after the premature birth of an illegitimate child. On admission to the asylum, two days after the be- ginning of her illness, she had a temperature of 103.2, a pulse of 128, respirations 56 per minute, intense exhaustion and collapse, muscular subsultus and constant moving about of her hands, a low, muttering de- lirium, with no memory, no power of attention, and no coherence. She gradually sank on the second day, her temperature rising to 104. This whole condition had arisen suddenly, and developed at once into great intensity. After death there was found inside the dura mater a loose membrane containing numerous spots of hemorrhage, the surface having a yellowish, sticky look. This extended all over the base of the brain. The lining membrane of the fourth ventricle was granular. On the auriculo-ventricular valves of the heart there were roughnesses with tough clots covering them. The womb and its appendages were normal for the period after delivery. In a case with such post-mortem appear- ances I was a little suspicious of syphilitic infection, considering the pre- mature labor and the meningeal appearances after death. I have gone carefully over the histories of all the puerperal cases that have been sent here during the past nine years. They were all under my own care, and the histories were taken on a uniform plan of my own by the assistant physicians. There were seventy-five cases altogether counted as puerperal, but fifteen of these were either old cases not sent in for periods over a year, or the same cases admitted twice during the same attack. These I omitted as having no clinical value. The re- 356 PUERPERAL INSANITY. maining sixty, on analysis and study of their characters and clinical symptoms and results, form a very instructive physician's lesson. Looking at their ages, it seems as if the disease occurred in just about the frequency that ordinary confinements oocur at the same ages. 1 Forty-four of the cases had never been insane before. In addition to the puerperal state as the great exciting cause of the disease in those sixty cases, I found that there existed as a predisposing cause a heredity to insanity in twenty -two of the forty -nine cases in which this point could be ascertained. No doubt heredity played a much more important part than this if the facts could have been accu- rately ascertained, but this is above the average of the ascertained heredity in our asylum tables for the same nine years. Moral causes acting during the puerperal state were common, such as the deaths of children, desertion of husband, frights,. etc. The incidence and importance of such causes of the disease are best shown by the fact that in thirteen, or twenty-five per cent, of the cases, the children had been illegitimate. The average rate of illegitimacy in Edinburgh is about one-third of this. Severe post- partum hemorrhage, or difficult or instrumental labors, had occurred in at least ten cases. But all these causes leave a considerable proportion of the cases where there was no exciting cause at all, except a normal labor and its accompaniments. Looking next at the question of which confinement the disease oc- curred most commonly after, I find that twenty cases, or one-third of the whole, occurred after first confinements. This is of course out of all pro- portion to the number of first confinements in the population. The remaining two-thirds happened, some in each confinement up to the eighth. This merely confirms what was well known before, that primiparce are most subject to the disease. Then as to the period of occurrence after confinement. In eighteen cases this was not precisely ascertained, but in nearly all these it was within the first fortnight. Of the remaining forty- two cases the disease began within the first week in twenty-one, and in eleven more within the second week, so that we may say that in eighty per cent, of the cases it began within the first fortnight. If that period is passed, it is clear that the chief risk is over in a woman in childbed from this disease, the first week being by far the most liable to its inva- sion. At least half the cases occur then. Only one case of the sixty occurred after the twenty-eighth day. The next point is very important clinically. Of the sixty cases no less than forty-three were very acute in character and symptoms, while seventeen only were mild and without acute symptoms. Twenty-nine of the forty-three acute cases were generally maniacal in character, and fourteen generally melancholic with motor excitement, some of each of these classes changing from one state to the other at times. In the mild cases the prevailing character was mental depression, fourteen of the seventeen being so. In at least eighteen of the acutely maniacal cases, 1 From 15 to 20 years of age in 3 cases. " 20 " 25 " " 16 " " 25 " 30 " " 20 " " 30 " 35 " " 9 " " 35 " 40 " " 12 " PUERPERAL INSANITY. 357 the mania amounted to absolute delirium, with no power of attention and no coherence of speech whatever. I know of no clinical form of insanity that would yield so large a proportion of very acute cases. Puerperal insanity may therefore be regarded as the most acute of all forms. The temperature of all cases on and after admission was taken. 1 It is always a most instructive record to look at the column of " highest tem- peratures" in each case. Of the sixty there were thirty-four cases under 99, and therefore they cannot be said to be above the average temperature of ordinary health, or at all events of the average temperature of the insane. But twenty-six cases, or forty-three per cent, of the whole, were over this, and of these fourteen cases, or twenty -three per cent, of the whole, were over 100. No other form of insanity shows this alarming result, for a tem- perature of over 100 I look on with alarm in any form of mental disease. The most serious part of it was, as we shall see, that all the deaths oc- curred in the cases with a temperature over 100. Yet to show that a high temperature, though alarming, is not necessarily prognostic of death, I find that of the five cases where it was over 103 three made excellent recoveries. I lately saw a case in private practice who recovered, and whose temperature had been over 105. The causes of the high tem- perature differed in different cases. The chief causes were (1) simple acute brain excitement ; (2) inflammation of the womb and surroundings, in some cases septic, in others simple ; (3) meningeal inflammation ; (4) incidental causes, such as malaria, mammary abscess, etc. The most common and one of the most important of all the symptoms present was the refusal of food paralysis of appetite. In thirty cases, or one-half of them, this was present. It could not be overcome but by the use of the stomach-pump or nose-tube in about ten cases. In a puerperal case refusing food I now use forcible feeding at once if food cannot be given in any other way. In no other kind of mental disease has the doctor's instructions to the nurse to be, "give much food and give it often." I am quite sure that most of the puerperal cases not septicoemic that die at home or in asylums die from want of early feeding. I give stimulants, too, in larger quantities with the food than in any other kind of insanity. I have seen the greatest and most evident good results from large doses of quinine as an antipyretic. In the case to which I have alluded where the temperature was over 105, every ten- grain dose of quinine was followed regularly by a fall of from 2 to 4 of temperature. There were many other symptoms, mental and bodily, very common besides a high temperature. Tenderness on pressure over the region of the womb was common, and whenever it is present I am in the habit of ordering warm water vaginal carbolized injections and warm slightly counter-irritating poultices over the abdomen, with sometimes blistering, over the pubes. Local abscesses in the ankles, fingers, wrists, and body 1 From 96 to 97 in 3 cases. " 97 " 98 " 10 " " 98 " 99 " 21 " " 99 " 100 " 12 " " 100 " 101 " 2 " From 101 to 102 in 3 cases. " 102 " 103 " 4 " " 103 " 104 " 3 " " 104 " 105 " 1 " " 105 " 106 " 1 " 358 PUERPERAL INSANITY. occurred in some cases. Muscular jactitation and subsultus occurred in some of the worst cases, but was not always followed by collapse. (Edema and albuminuria were present in two cases, and convulsions in one. Of the mental symptoms, one of the most important from its great frequency was the suicidal impulse. It was present in twenty-five cases, or forty per cent, of the whole. It was present in an impulsive form in many of the maniacal as well as some of the melancholic cases. No medical man, therefore, in treating a case of puerperal insanity, but should keep in mind that the patient may attempt suicide, and he should warn the nurses and attendants of this. The presence of hallucinations of the senses, especially of hearing, I was surprised to find so common. They occurred in at least one-third of the cases, and were very often persistent, as hallucinations of hearing are apt to be, after the other symptoms were passing off. But they did not indicate incurability, as is the case so often in chronic auditory halluci- nations of alcoholic origin. The patients in many cases passed from the acute stage into one of stupor, and in some this existed from the beginning. At one part or other of the case stupor was present in at least fifteen cases, or twenty- five per cent. It was connected, I fear, in some of them with the habit of masturbation, to which puerperal cases are very subject. Neither the stupor nor the masturbation indicates incurability. One case in which both were the most prominent symptoms recovered. The last and most important point brought out in this study of these sixty puerperal mental cases is the great curability of the disease. Thirty- three cases were discharged recovered, and seventeen were discharged much improved. Of the latter the prospects of complete recovery were very good. I actually know they did complete their recovery in twelve cases. That is, forty-five cases out of the sixty recovered, which amounts to a recovery rate of seventy-five per cent. Most of the recoveries took place quickly. In three months from the beginning of the attack over one-half of the cases were well, and in six months ninety per cent, of those who recovered were well. But to prevent anything like loss of hope, I mention that one of the melancholic cases with stupor recovered after the disease had existed for four years. No recoveries from mental disease are generally better or more satisfactory than those from puerperal insanity. In some cases recovery was very rapid indeed after it began. In the cases where stupor existed or supervened on acute insanity, the occurrence of menstruation seemed often to act as the exciting cause of recovery. I myself believe that this was mostly a coincidence, or rather I should put it that sanity was the mental, and menstruation the chief bodily symptom of the restoration of brain and body to their normal working. It is the proper mode of treatment, however, whenever a puerperal case gets strong in body and the body weight becomes normal, to use every means to restore menstruation if it has not returned. Warm baths at night, mild shower-baths in the morning, hip baths with mustard, aloes, and iron pills, and borax at the time menstruation is expected, are all useful in addition to the general tonic and fresh air treatment. Men- struation returning before the general strength is improved is usually a LACTATIONAL INSANITY. 359 bad thing, for it is apt to be attended with increased mental excitement, and is apt to become menorrhagic. Looking at curability of the cases according to their characters of acuteness or mildness, and of mental exaltation or depression, I find that the forty-three acute cases recovered in the proportion of eighty-one per cent., and the seventeen mild cases in the proportion of only sixty- two per cent. But then it must be kept in mind that the mild cases were longer in being sent into the asylum, and of the total number of mild puerperal cases occurring, the most intractable and prolonged would be the only ones sent into the asylum, the rest would recover at home. Of the exalted and depressed cases (mania and melancholia), an almost equal proportion, that is seventy-five per cent., of each recovered. Five of the sixty cases died, four of them within a month of the onset of the disease, and one within two months. This is a mortality of 8.3 per cent, of the cases. No cases are more difficult to get post-mortem examinations in than puerperal cases, and they were performed in only three of the five cases. The cause of death in one was found to be phthisis pulmonalis, under which the patient had labored for long before her con- finement, and which as usual advanced rapidly after parturition ; in another it was septicaemia ; and in the third simple maniacal exhaustion, without symptoms of septicaemia. There is no doubt, however, that the chief cause of death in puerperal cases that have been properly fed is septicaemia. They are, in fact, cases of combined puerperal fever and puerperal mania, the mania having more of the character of delirium than of ordinary insanity. It is curious that there was no history of preliminary chill in the septicaemic cases. As I said, I do not like the temperature to run up much above 100 in puerperal cases. Of the fourteen cases in which this took place five died, or thirty-five per cent. I still less like to see muscular subsultus with a restless moving of the hands and twitching of the facial muscles. There may be septicaemia in a puerperal case with purulent peritonitis, metritis, and phlebitis, and yet the patient never complain of any local pain, and even on pressure there may be no uterine or peritoneal tenderness. 1 Many of the cases with the worst symptoms, bodily and mental, made good recoveries. LACTATIONAL INSANITY. Nursing in women is the cause of mental disease sometimes. The poor are more liable to this than the rich, both being equally subject to puerperal insanity. This is as might be expected. If the wife of a laborer has had ten children and nursed them all, if she has, during all the years those ten pregnancies and childbirths and nursings have been going on, had to work hard, if she has had to struggle with poverty and insufficient necessaries of life in addition to this continuous repro- ductive struggle and family worries, if in addition to all this she has in- herited a tendency to mental disease, no physiologist or physician can 1 These statistics may be carefully compared and supplemented by Dr. J. Batty Tuke's statistics, obtained from an analysis of cases in this asylum, in the Edinburgh Medical Journal for May, 1865. 360 LACTATIONAL INSANITY. wonder if she should become insane during the tenth nursing. Indeed, the wonder is that any organ ism could possibly have survived in body or brain such a terrible strain and output of energy in all directions. Such a woman often enough becomes insane during a nursing long before the tenth. An organic sense of duty and a stern physiological necessity among poor women compel them to nurse their offspring. What else can they do ? It is well for the offspring, but the mother often enough dies, or is upset in body or brain in the attempt. A typical case of lactational insanity is one occurring in the case of a poor woman who has had several children, and has nursed the last for several months, who has got pale and thin in the process, and become subject to headaches, noises in her ears, giddiness, flashes of light before her eyes, lassitude and nervous irritability, in fact to the usual symptoms of general bloodlessness and brain anaemia. She then gets depressed in mind, her sleep leaves her, her self-control is lost, and she becomes either lethargic and stupid or suicidal, with delusions that her husband and neighbors are against her, thereby, poor woman, merely misinterpreting her sensations of mental pain and distress. She had little organic strength for her pregnancy, still less for her delivery, and it has quite broken down in her nursing. To such a woman the organic delight of suckling her infant, for which the maternal nature craves and is satisfied by the process, becomes an irritation, an excitement, and an exhaustion. But such a typical case, if taken in time, and if nursing is stopped and rest is given, with good, nourishing food, malt liquors, and iron and cod-liver oil, and fresh air, at once begins to amend, sleeps, acquires self-control, ceases to imagine things that have no objective existence, puts on flesh, begins to employ herself, gets cheerful, and is quite well and strong in three months, her blood containing many more blood corpuscles than it had when treatment was begun, and the renourished brain resuming all its normal functions in a normal way. But cases of lactational insanity vary greatly in form, degree of mental disturbance, and duration of attack. It must be admitted that they do not follow one type. They are nearly all melancholic at some period of the attack. They nearly all suffer from premonitory neuroses of sensation in the shape of headaches, lassitude, neuralgia, feelings of sinking at pit of stomach, or some of the other signs of anaemia and ill-nourishment. They are all very curable if put under proper treatment in proper time. The following case is an almost typical one, except that the first part of the asylum stage of it was more acute than usual : K. J., aet. 40, the wife of a plumber, who earned when in full work twenty-eight shillings a week, has had seven children in sixteen years, and nursed each about fifteen months. There is no known heredity to insanity. She nursed the last child for twelve months, and of course had to do her family duties meanwhile. Her first symptoms were great depression and want of energy. She would sit for hours doing nothing, saying nothing, and taking no notice of anything. Her brain seemed to have been exhausted in its power to energize mentally. Then she began to be restless and sleepless, and her head felt sore and queer. Soon she became delusional fancying she saw friends in the street who were in the colonies. She was sent at first to the Royal Infirmary here, but proving unmanageable LACTATIONAL INSANITY. 361 there, she was at last sent here. On admission she was markedly de- pressed, and the mental working of her brain was enfeebled in such a way that she would begin a sentence in answer to a question, and would stop in the middle, her volitional power having run short apparently. She rambled in speech and mistook the identity of persons round her. She had the delusion that she was to be burned at the stake. She was thin, pale, muscularly feeble, lacking in energy, with blunted sensibility. Her special senses were blunted, pulse small and weak, temperature 98.8. After admission she was sleepless, restless, and acutely excited for a week. Then she became more quiet, with short intervals of almost sanity, but with impulsive action. Sitting quietly sewing in a room with others, she would suddenly drop on her knees and pray aloud. Was put on extra diet, with porter and quinine and iron. She always got worse and more delusional in the evening, this fact probably indicating that by that time her brain power was getting exhausted. But she steadily picked up in flesh arid strength, mental and bodily, and in ten months was discharged almost recovered, having gained twenty-four pounds in weight, and looking fresh and healthy. What will happen if she has more children, and nurses each of them fifteen months, can easily be conjectured. The treatment of lactational insanity is simple and physiological. Stop the nursing, give nourishment in abundance with some malt liquor, change the scene, free the patient from family cares for a time, give quinine, iron, cod-liver oil, and tonics generally. The suicidal tendency must be thought of and guarded against if present, as it is in a very large proportion of the cases. A survey of my nine years' clinical experience in the Royal Edinburgh Asylum, 18741882, in regard to lactational insanity is instructive. We have had altogether fifty-two cases that I classified as lactational. But some of these were old cases of the disease transferred from other asylums, or readmitted, and those I shall take no notice of. Their study would lead to no good clinical results, and would merely tend to confusion. Forty of the cases were admitted laboring under recent lactational in- sanity, and of these only I shall speak. As classified on admission, twenty-one of these were cases of mania and nineteen of them of melan- cholia. Only about half of these twenty-one cases of mania had mental exaltation as their predominant feature throughout their whole course, the others beginning with marked melancholic symptoms or ending with them. But the fact that half the cases were maniacal during their most acute, period shows that the insanity of lactation is by no means exclu- sively a melancholic form of mental disease. It shows that bodily and nervous exhaustion and malnutrition, though their first mental symptoms may be mental depression, yet tend in a large number of cases towards morbid mental exaltation in the long run, mania being in fact another and a further stage of the convolutional brain disturbance. When classified according to the acuteness or mildness of their symptoms, in- dependently of psychical exaltation or depression, I find there were twenty- two acute cases and eighteen mild ones, the majority (eighteen) of the acute cases being maniacal, and a majority (thirteen) of the mild cases being melancholic. As regards the months of nursing in which the disease occurred, my 362 LACTATIONAL INSANITY. records do not state this point in seventeen, but of the remaining no less than ten occurred within the first three months, seven in the next three, four in the next three, and only two in the last three months. I confess I was surprised at this. It is a different result from that arrived at by Dr. Batty Tuke from an examination into the statistics of fifty-four cases of the insanity of lactation that had been in this asylum previous to May, 1865. Only two of his cases occurred within the third month, and only eight within the first six months of nursing, while twenty-one cases, or fifty-one per cent, of those in whom the period was recorded, occurred after the ninth month of. nursing, my percentage for the same period being nine. Such a diversity of results is enough to make one despair of the value of looking at clinical facts in a statistical form. My statistics distinctly point to the causation of this form of mental disease being largely due to the disturbance of the puerperal period aggravated by the reflex excitation of the brain through the physiological act of suckling the infants. Dr. Tuke's statistics clearly point to a preponderating causation by the exhaustion of mere long-continued nursing. Both causes operate, I have no doubt, but why they should have operated so differently in the cases in the same asylum at different periods I am unable to explain. My records were so deficient in regard to which nursing the disease oc- curred in as to be worthless. They merely show that lactational insanity may occur after the first child or the seventh. The suicidal impulse is common, seventeen of the forty having had it in greater or less intensity. The temperature shows a very marked difference from the puerperal form of insanity. 1 A glance at the highest temperature shows that only about one-third of the cases (thirteen) were over the normal standard, and of these, the great majority (eight) were only between 99 and 100. Three were between 100 and 101, leaving only two that were over that, in one of whom it was caused by an inflamed breast. The temperature record shows clearly the milder type of lactational insanity as compared with the puerperal form. The thermometer, though the readings seldom reach very high in uncomplicated mental disease, I look on as being simply invaluable as showing the intensity of the brain action. Its readings upwards, from normal to 102 or 103, are usually in an exact ratio to the intensity of the mental disease. Only, it must be re- membered, that half a degree in the estimation of the intensity of brain overaction is equivalent to two degrees in the measurement of febrile disturbance. I attach especial importance to the readings of the ther- mometer in all acute mental diseases, and have used it in everjr case under my care in the Carlisle and Royal Edinburgh Asylums for the past sixteen years. Heredity to insanity was known to be present in fifteen of the cases ; but then in twelve of the forty no reliable information on this point could be got. And as proximate causes, mental and moral disturbances oc- curred in nine of the cases. Let us look now at the results of treatment, that most interesting of 1 From 96 to 97 C " 97 " 98 C " 98 " 99 " 99 " 100 1 case. 6 " 20 " From 100 to 101 in 3 cases. " 101 " 102 " " " 102 " 103 " 1 " " 103 " 104 " 1 " THE INSANITY OF PREGNANCY. 363 all questions to the physician, and still more so to the relatives of the patients. Thirty-one of the forty cases recovered, and three more were removed from the asylum uncured but improving. This is seventy-seven and a half per cent, of actual recoveries, and a still higher figure of po- tential restorations to mental health. The lactational cases recovered in slightly larger numbers, therefore, than the puerperal cases, and only one case of the forty died. I find that the maniacal and the melancholic, the acute and the mild cases recovered in somewhat equal proportions. 1 The six who did not get better, but are still under treatment, were three of those patients who had repeated attacks of insanity before, the other three looking phthisical. The lactational cases did not recover as soon as the puerperal. 2 Only sixteen recovered within three months, but twenty-five, or sixty-two per cent, of all the cases, and eighty per cent, of the recoveries, recovered within six months, and all of them within eighteen months. And they made good and lasting recoveries, few of them relapsing. Recovery in all the patients was accompanied by a great increase in body weight, in strength, in appetite, and in fatness. In some menstruation continued during the disease, and in its earlier stages acted as an excitant and exhauster of strength. It was often menorrhagic in such cases. The function when absent usually returned of itself without any special treatment as the nutrition improved. One instructive fact I came across in relation to this disease. Out of one hundred and sixty-six admissions of ladies to our higher class de- partments there were only two lactational cases, while there were among them the usual proportion of puerperal cases. Out of 1383 pauper and poorer private female patients, there were thirty-eight lactational cases. In short, the puerperal cases were sent for hospital treatment in as great a proportion among the rich as the poor, while the lactational cases were only sent in half that proportion. This points clearly to the greater mildness of type of the latter, and the possibility of treating it at home, if not to the greater infrequency of the disease among the well-fed classes, who have nurses to attend their children and doctors to tell them when to stop nursing in time. Probably the custom among the poor of nursing each child a long time in order to delay the conception of the next has something to do with the greater prevalence of this form of mental disease among them. THE INSANITY OF PREGNANCY. Few women carry a child without being influenced mentally thereby in some way or other. The psychology of pregnancy has yet to be written in a scientific way. There are innumerable facts on record, but 1 Of the twenty-one cases of mania fifteen recovered ; of the nineteen cases of melan- cholia sixteen recovered ; of the twenty-two acute cases fifteen recovered ; and of the eighteen mild cases sixteen recovered. 3 Within 1 month 6 cases recovered. i Within 7 months 1 case recovered. 26 " 8 " 1 " 34 " 9 " 2 " 42 " 11 " 1 " 66 " 18 " 1 " 6 1 364 THE INSANITY OF PREGNANCY. they are scattered and undigested. Without going into the domain of mental disease in any technical sense, we find examples of partial mental exaltation, mental depression, mental enfeeblement, mental paralysis, and mental perversion. No doubt the alterations are chiefly in the affective faculties, but the reasoning power, the moral sense, the voli- tional power, the imagination, and even the memory, are often enough affected in pregnant women. As a part of the nervous disturbance the bodily appetites become changed, the physiological functions altered, and the nutrition of organs profoundly affected. In this state many women have endless caprices, unfounded dislikes and likings, cravings for foods and drinks never before desired, unnatural desires for indigestible things, causeless weeping and laughing, stealing and lying, morbid thirst and hunger, an activity of digestion never before known, pigmentation of the skin, alteration of the expression of the face, of the tones of the voice, and of the power of muscular coordination. It is scarcely surprising that every function of the great central nervous system should be thus affected in many cases, for, physiologically, pregnancy means a dynamical change for the time being in the direction of some of the great currents of energy, and a change, amongst others, in the quality of the blood. Psychologically it is the fulfilling of the second strongest organic necessity of life, to reproduce the species. All the changes, mental and bodily, that I have referred to, and far more than these, should be taken into account in studying the question of how pregnancy produces those great psychical disturbances that we call insanity in brains predisposed thereto. A vast number of women are mentally unsound during pregnancy, if judged by an ideal standand of volitional power, while very few indeed pass the conventional line that divides sanity from insanity. Nature seems to care for pregnant women physiologically in all directions, and does so in the case of the mental functions of the brain convolutions. Those may be, and are often, affected in pregnancy, but are seldom quite upset. It is a very rare form as an insanity, as we shall see from the statistics. In fact, there is no period in the life of a woman after the age of twenty- five when she is less liable to actual insanity than during her pregnancies. But there is a type of case exactly the contrary of this rule, where a woman cannot become pregnant without becoming insane. I have such a patient now, who has been five times pregnant and five times insane, each time during pregnancy. This no doubt is the clearest indication nature could give that such a person should never become pregnant. I had one patient, K. L., who had six different attacks of insanity two of pregnancy, two of puerperal, and two of lactation and she made perfect recoveries from them all, though in each she was most deter- minedly suicidal and homicidal, strangling and killing her first child, and attempting at least six different times to take away her own life. Yet for the last seven years she has kept quite well, and done her work at home. She had one or two other children without being affected in mind more than by a little depression. The typical mental disturbance of pregnancy of the mild kind not re- quiring asylum treatment, and often not incapacitating a woman from doing her duties, consists of a mental depression, or mental apathy not amounting to stupor, with a loss of interest in things, a loss of conscious THE INSANITY OF PREGNANCY. 365 affection for husband and sometimes for children, a slight weariness of life, a fear of something going to happen, and a general loss of courage and a disinclination for social intercourse. These symptoms do not usually come before the third month of pregnancy, and much more fre- quently they do not come on till after the sixth month. Sometimes they only last for a part of the period of pregnancy and then pass off. More usually they do not disappear till after delivery. They either do so then or become aggravated into a more acute puerperal psychosis. There is another distinct type of case where during the first pregnancy insanity comes on, becomes acute, and ends in dementia soon. This is no doubt one of nature's ways of ending a bad stock ; just as I look on the in- sanity of adolescence to be, and on sterility to be in some cases, and on sexual antipathy to be, and on absence of the social instincts. There are psychological bachelors and old maids, born so, whom no social cultiva- tion or opportunity can make otherwise, and these will be found to occur usually in families with a heredity to insanity. This case presents the most common type that family doctors have to do with : K. M., a married woman, aet. 34, with an insane heredity, who had borne five children comfortably, came to me saying she was dull and miserable, and could not do her work nor take an interest in any- thing. It seemed as if she did not care for her husband, nor to do her household duties, and she said she was afraid of herself, meaning that she might commit suicide. She was stout, strong, and well-nourished, and looked the picture of good health. She slept well, ate well, and all her bodily functions were normal. She was in the sixth month of pregnancy, and the mental change had come on a month before. I advised that she should have a female friend with her, and should go on doing her work, should walk much in the fresh air, and wait patiently for her confine- ment. After the eighth month she felt much better, and after confine- ment every trace of her mental depression left her. The following was a very acute case of the insanity of pregnancy : K. N., set. 32, pregnant of an illegitimate child, became at the sixth month dull and apathetic, then within a month incoherent, talkative, and almost delirious. She would moan at times as if in pain ; would say, poor soul, "I am in a fearful state ; never was in such a state as this." She had hallucinations of sight, seeing elephants all of a green color before her. She was very weak on admission, could not walk well with- out assistance, her tongue and mouth tended to be dry, she had pain in her abdomen, her ankles were swollen, her pulse was 136 and weak, and her temperature 100.4. She continued restless, depressed, excited, and sleepless, and eight days after admission was delivered of a healthy male child. Her mental state improved much thereafter for a week, when she had a relapse. In fact, the puerperal state caused an access of puerperal insanity, but in four weeks after the birth of the child the excitement had passed off, the delusions only remaining. In another week the de- lusions, too, had left her, and in two months she was discharged strong in body and well in mind. The next is a more characteristic case, K. 0., aet. 30, a married woman with a hereditary history of insanity, and pregnant with her first child, became insane six weeks before its birth ; a fear came over her 366 THE INSANITY OF PREGNANCY. first, and she said, "I must die, I must die." An inflammation in one lung had reduced her strength, and she had been sleepless for two weeks, soporifics having no effect. She was suicidal, and tried to jump out of a window. Her friends properly kept her at home, nursing and looking after her as best they could till the child was born. She then got much worse mentally, and remained maniacal for two months. Then she became apathetic, confused, and childish, with occasional impulsive spurts of maniacal excitement. This state lasted for a month, then she began to improve, and was well in six weeks, her attack having lasted altogether five months. The bromides and iron were used largely in the acute stage of her disease. Strychnine in the apathetic stage, and extra food and fresh air and good nursing throughout. The cases of the insanity of pregnancy of such an acute type as to need asylum treatment are rare and by no means of a uniform type. I have had only fifteen such in the past nine years sent to the Royal Edinburgh Asylum ; nine of these were maniacal and six melancholic ; nine of an acute type, and six were mild in their symptoms ; seven of them were suicidal, some being desperately so. This is an enormous proportion of suicidal cases for any kind of insanity. In half of those with a history there was heredity to insanity, mostly strong and direct heredity. Of the fifteen cases only nine recovered, or sixty per cent, of the whole, this form of mental disease in its worse forms being thus more incurable than the insanities of childbed or nursing. The time of re- covery in relationship to confinement was various. In only two cases of the nine who recovered was the termination of pregnancy attended with speedy and marked mental recovery. In four cases confinement dis- tinctly aggravated the previously existing mental disease. In three of these, in fact, the symptoms had not been so bad before confinement as to need asylum treatment at all. The puerperal state seemed to bring the insanity of pregnancy to a climax in those cases. In three cases of the nine who recovered they got better, and were discharged from the asylum recovered before they were confined. The whole nine had re- covered in six months. Three cases were transferred to other asylums within four months after admission here in an improved condition, and of these one might possibly have got better ultimately, and one was taken home before recovery and did get quite well. This would bring up the recovery rate to seventy-three per cent. Two died, one of uraernic poisoning (this probably having been the real cause of her insanity) in seven days after admission, and another of general tuberculosis in ten months. Women are more liable to become insane during the first than subse- quent pregnancies ; for seven of the fifteen cases were first pregnancies ; and the fact that five of the fifteen were illegitimate children, shows that moral causes largely bring on the disease. The coming on of the disease was gradual in most of the cases, and it began in all but two with depression of mind or apathy and stupor. The affection towards their husbands became perverted in nearly all the married cases. The psychology of the affection between husband and wife, and the way it is influenced by sexual intercourse, by pregnancies, by the children or the absence of children, by neurotic constitution of THE INSANITY OF PREGNANCY. 367 brain, by the climacteric, and by old age, has yet to be written from the physiological point of view. Many strange chapters on this subject could family doctors write. I have not had a single case of the insanity of preg- nancy in a rich patient sent here. This is natural and proper, for if any kind of mental disease should be kept out of asylums without sacrificing life or recovery, it is this. It would be a terrible fate, as things go in this world, to be born in a lunatic asylum, in addition to being the child of an insane mother. The asylum cases cannot be taken as the real type of the insanity of pregnancy. The treatment of the insanity of pregnancy is in no way special. The women are not usually run down. The temperature in only four of my cases (one being the uraemic case) was above 99. Fresh air, exercise, watching, nursing, employment, cheerful society, change, freedom from too much work and worry, and suitable food, are about all we can do. Slight sedatives may be required as placebos, but in as small doses and as seldom as possible. The blood of an insane mother needs not to be mixed with morphia or chloral to make it bad for her unborn progeny. The tendency to suicide must be specially kept in mind. One of my cases had a secondary syphilitic eruption and needed treatment for that, and in two more I suspected syphilis, both children being prematurely born dead. Together the insanities of childbed, nursing, and pregnancy have con- stituted over nine per cent, of all the female cases in the Royal Edinburgh Asylum for the past nine years (18741882), there being 141 cases out of 1549 admissions (including readmissions). There was 5 per cent, of the puerperal form, 4 per cent, of the lactational, and 1 per cent, of the insanity of pregnancy. As we admit all classes of society, this may be taken to represent the real effect of childbearing in the production of in- sanity, at least in this part of the country. In Cumberland and West- moreland for the ten years (18631872), during which I was in charge of the Carlisle Asylum (for the poorer classes only), there were 75 cases out of 431 female patients in all, or 17.4 per cent. This enormous dif- ference of nearly twice the proportion is made up entirely of the excess of puerperal cases, there having been 51 of these, or 11.8 per cent, of the whole of the female insane of those two counties. That is more than twice the Edinburgh proportion. Such great differences in the local dis- tribution of the different forms of insanity is an interesting problem in medico-psychology that needs to be worked out as to its causes. LECTURE XVI. THE INSANITIES OF PUBEKTY AND ADOLESCENCE. WHEN one considers the enormous differences in the physiological life and prevailing brain activity of the same human being at the different periods of life, it does not seem wonderful that each period has its own type of psychological disturbances, just as it has its special kinds of ordi- nary disease. Indeed, it would be very wonderful if the brain of a child, whose chief characteristics are active development, intense inquisitive- ness in all directions, great sensitiveness to impressions, which succeed each other rapidly, and, whether they are painful or pleasurable, leave only slight lasting traces, if this organ manifested quite the same dis- turbances when its mental functions become deranged as the brain of an old man, whose chief characteristics are retrogression in all its activities, and insensitiveness to ordinary impressions. The essential qualities of the two organs are in many respects different ; their receptive, dynamical, and trophic activities are quite dissimilar. Then what a change in the mental activity of the brain does the period of puberty cause ! Looking at the matter from the combined point of view of physiologists and psy- chologists, we must connect the new development of the affective faculties, the new ideas, the new interests in life, the new desires and organic cravings, the new delight in a certain sort of poetry and romance, with a new evolution of function in certain parts of the brain that had lain dormant before. This awakening into intense activity of such vast tracts of encephalic tissue, though provided for in the evolution of the organ, does not take place without risk of disturbance to its mental functions, especially where there is an inherited predisposition in that direction. And if this predisposition is thus developed into actual derangement of function, it happens, as might have been surely predicted a priori, that the type of derangement is much influenced by the great function of the reproduction of the species then arising de novo. To form a right con- ception of the kinds of mental disease that occur at the various important periods of life it is essential that we consider them in connection with the normal changes that take place in the organism at these periods, with the normal modifications in the mental energy at those periods, and with the changes that take place in the brain texture and mode of action, so far as we know them. In short, we must take a physiological view of mental disease. THE PERIOD OF PUBERTY OR PUBESCENCE. The period of puberty is the next great physiological era in the life of man after that of birth. Before that occurs the whole trophic and mental energy has been occupied in acquisition alone. There has been no production. Before that time there has been a general psychical likeness between individuals INSANITIES OF PUBERTY AND ADOLESCENCE. 369 of the same and of opposite sexes which then rapidly disappears. Individualities of all kinds spring up far more decidedly at that time in those of the same sex ; while, dividing the sexes at this time, there arise most striking psychical differences that far exceed the bodily contrasts. Up to that time the mental development of each sex has heen very much in the same direction ; after puberty that development takes place in the man far more in the direction of energizing and cognition, in the woman in the direction of emotion and the protective instincts. But these changes do not ordinarily take place all at once in the human species, any more than a full capacity for reproduction takes place in either sex immediately the testes assume their function, or menstruation and ovulation are set up. It takes several years for the full development of the size and form of the body that is normal and typical for each sex, and it takes still longer for the complete evolution of the masculine and feminine psychical characteristics. It is not at the time of the first appearance of the reproductive function chiefly that there is peril to the healthy mental balance, but those after-years of gradual coming to maturity are often full of danger to the mental health of both sexes. It cannot be otherwise. The hereditary influences and tendencies that all the former generations have transmitted to a man come then most fully into play. And when we consider for a moment that it is not only his father's and his mother's own inherited tendencies that may come to him, but their acquired peculiarities as well, and not only so, but the inherited and acquired peculiarities of his four grandparents and his eight great- grandparents, not to go any further back, how great a risk does every man and woman run of suffering for the sins of their fathers ! Maudsley speaks of a man's yielding to the tyranny of his organization. We might go further, and say he may fall a victim to his grandfather's excesses. Most fortunately for the race, there are other influences obviating such effects of heredity. One is that the tendency towards reproducing the normal and healthy type is generally stronger than towards the abnormal. If the conditions of life are favorable, mere ten- dencies never develop, and potentialities never become actualities. The other is, that when the tendency to abnormality is strong the victim of it often dies before the age of reproduction, or he is incapable of procreation. Now, the insanity of puberty is always a strongly hereditary insanity ; it, in fact, never occurs except where there is a family tendency towards mental defect or towards some other of the neuroses. Its immediate cause may be some irregularity in the coming on of the reproductive or menstrual function ; its real and predisposing cause is heredity, having for its object this higher physiological law, that the reproduction of the species is stopped when the inherited tendency to brain disease acquires a certain strength in any individual. I cannot help here adverting to the absurd and unphysiological theories of education which are sometimes taught, and which we as medical men should combat with all our might. The old practice of attending to the acquisitive and mnemonic faculties of brain alone in education is now fortunately giving way. The theory of any education worth the name should be to bring the whole organism to such perfection as it is capable of, and to train the brain power in accordance with its capacity, most 24 370 INSANITIES OF PUBERTY AND ADOLESCENCE. carefully avoiding any overstraining of weak points and an apparently strong point in the brain capacity of a young child may in reality be its weakest point in after-life. I have known a child with an extraordinary memory at eight, who at fifteen could scarcely remember anything at all. Then as the age of puberty approaches, one would imagine, to hear some scholastic doctrinaires talk, that it was the right thing to set ourselves by every means to assimilate the mental faculties and acquirements of the two sexes, to fight against nature's laws as hard as possible, and to turn out psychically hermaphrodite specimens of humanity by making our young men and women alike in all respects, to make our girls pundits and doctors, and our young men mere examination-passers. If there is any- thing which a careful study of the higher laws of physiology in regard to brain development and heredity is fitted to teach us, it is this, that the forcing-house treatment of the intellectual and receptive parts of the brain, if it is carried to such an extent as to stunt the trophic centres and the centres of organic appetite and muscular motion, is an unmixed evil to the individual, and still more so to the race. There is no time or place of organic repentance provided by nature for the sins of the school- master. Some educationalists go on the theory that there is an unlimited capacity in every individual brain for education to any extent, in any direction you like, and that after you have strained the power of the mental medium to its utmost, there is plenty of energy left for growth, nutrition, and reproduction. Nothing is more certain than that every brain has at starting just a certain potentiality of education in any one direction and of power generally, and that it is far better not to exhaust that potentiality, and that if too great calls are made in any one direction it will withdraw energy from some other portions of the organ. These persons forget that the brain, though it has multiform functions, yet has a solidarity and interdependence through which no portion of it can be injured or exhausted without in some way interfering with the func- tions of the other portions. Even the very anatomical and histological composition of the organ might teach us this. The way in which its several elements that minister to mental functions, motion, sensation, regulation of temperature, and nutrition, are mixed up in the cortex, and even in the centres lower down, have as yet defied our anatomical and physiological investigations even to distinguish the one clearly from the other. To expect that any one man could have the biceps of a blacksmith, the reasoning powers of a Darwin, the poetic feeling of a Tennyson, the procreative power of a Solomon, and the longevity of a Parr, is simply to expect a physiological miracle. As Mr. G. H. Lewis 1 says : " Owing to the action and reaction of blood and plasm ode, of tissues on tissues, and organs on organs, and their mutual limitations, the growth of each organism has a limit, and the growth of each organ has a limit. Beyond this limit no extra supply of food will increase the size of the organism, no increase of activity will increase the (power of the) organ 'Man cannot add a cubit to his stature.' The blacksmith's arm will not grow larger by twenty years of daily exercise after it has 1 Physical Basis of Mind, p. 184. INSANITIES OF PUBERTY AND ADOLESCENCE. 371 once attained a certain size." The possible extent of development of every brain and of every function in any one brain is just as much con- fined by limitations as the size of the blacksmith's arm, and physiology teaches us that no organ or function should be worked even up to its full limit of power. No prudent engineer sets his safety-valve just at the point above which the boiler will burst, and no good architect puts weight on his beam just up to the calculation above which it will break. Nature generally provides infinitely more reserve power than the most cautious engineer or architect. She scatters, for instance, seeds in millions for hundreds to grow, and she is prodigal of material and strength in the heart and arteries beyond what is needed to force the blood-current along ; therefore we have no reason to think that any function of the brain should be strained up to its full capacity except on extreme emergencies, or that any of the receptive or sensory brain-tissues should be stored choke-full of impressions for the purpose of being frequently called up again as representations. Especially do these principles apply if we have transmitted weaknesses in any function or part of the organ ; and what child is born in a civilized country without inherited brain weaknesses of some sort or in some degree ? These principles also apply, I believe, most strongly to the whole reproductive functions of the body and its centres in the brain, both in the male and the female. Especially are they applicable in the case of the female organism, on which the chief strain of reproducing the species rests. The risks to the mental functions of the brain from the exhaust- ing calls of menstruation, maternity, and lactation, from the nervous reflex influences of ovulation, conception, and parturition, are ruinous if there is the slightest original predisposition to derangement, and the normally profound influences on all the brain functions of the great eras of puberty and the climacteric period are too apt, in these circumstances, to upset the brain stability. Beyond all doubt, boarding-school education has not as yet been conducted on physiological principles, and is respon- sible for much nervous and mental derangement, as well as for difficult maternity ; but if the education of civilized young women should become what some educationalists would wish to make it, all the brain energy would be used up in cramming a knowledge of the sciences, and there would be none left at all for trophic and reproductive purposes. In fact, for the continuance of the race there would be needed an incursion into lands where educational theories were unknown, and where another rape of the Sabines was possible. American physicians tell us that there are some schools in Boston that turn out young ladies so highly educated that every particle of their spare fat is consumed by the brain-cells that subserve the functions of cognition and memory. If these young women do marry, they seldom have more than one or two children, and only puny creatures at that, whom they cannot nurse, and who either die in youth or grow up to be feeble-minded folks. Their mothers had not only used up for another purpose their own reproductive energy, but also most of that which they should have transmitted to their children ; nature, no doubt, making provision for the transmission of the unused-up energy of one generation on to the next, on the principle of the conservation of force. As physicians the priests of the body and the guardians of 372 INSANITIES OF PUBERTY AND ADOLESCENCE. the physical and mental qualities of the race we are, beyond all doubt, bound to oppose strenuously any and every kind and mode of education that in any way lessen the capability of woman for healthy maternity, and the reproduction of future generations strong mentally and physically. Why should we spoil a good mother by making an ordinary grammarian ? The relation of the psychical and emotional development to the generative function is full of interest and importance to us as physiologists, and few men have been long in practice before such questions obtrude themselves as very practical ones indeed. The first hysterical girl a man has to treat in a good family, where he does not want to lose the case or the family practice, may test severely his knowledge of the reflex relationship of the uterus with the sensory, motor, and mental functions of the brain. We must, as much as we can, study the conditions and relations of phenomena of all kinds. It is a mere cloak for ignorance, and an excuse for not thinking, to call certain abnormal phenomena "hysterical," and imagine that explains them. It does not require much consideration to see that at the period of puberty in both sexes, but especially in the female, the direct connection of certain physiological functions and processes with certain mental facts influences the whole life of the individual. If that connection is in any way abnormal, we have great strains on the mental functions of the brain, and sometimes actual derangement. Our high civilization and refinement, no doubt, add immensely to the risks by increasing the strain. The psychological analysis of what female modesty is, by a physiologist, reveals the transformation and apotheosis in the higher regions of the brain of reflex impressions from the reproductive organs into a high moral quality, not only beautiful, but absolutely essential to social life. How can a physician understand the true import of the obtrusive and grotesque modesty of a hysterical patient except he takes this into account ? The intense and complete outward repression and inhibition of certain physiological cravings required by our morals and our civilization cause, no doubt, a dangerous strain on the brain functions, and a reaction in other directions, where there are hereditary neurotic weaknesses. Puberty is the first really dangerous period in the life of both sexes as regards the occurrence of insanity ; but it is not nearly so dangerous as the period of adolescence, a few years afterwards, when the body, as well as the functions of reproduction, have more fully developed. The nutri- tive energy of the brain is so great in youth, its recuperative power so vigorous, and its capacity for rest in sleep so powerful, that its mental functions are not often upset at this period. To bring out this fact statistics are useful. In Scotland, at the present time, nearly one-half the population are under the age of 20 ; while in the Royal Edinburgh Asylum we have, out of a total of 730 patients, only ten under that age. The contrast between 50 per cent, and 1.5 per cent, in the sane and insane populations is a very marked one. But, to show how different is the state of matters in the older periods of life, let us compare the num- ber of persons over 60 in Scotland and in the asylum. In the general population there are just about 8 per cent, over that age, while in the asylum, out of the 730, there are no less than 126, or 17 per cent. Or, to bring out the facts differently, it is found that the number of people INSANITIES OF PUBERTY AND ADOLESCENCE. 373 so insane as to require to be sent to asylums is about one in 600 of the population. Now, at this rate, our 730 inmates represent an ordinary population of 438,000. One-half of these, or 219,000 persons, are 20 years of age or under, and they have only supplied ten of our lunatics, insanity occurring in them at the rate of only one in 21,900, while the remaining half of the general population, that over 20, had produced 720 lunatics, or one in 304, that is, in seventy times the proportion of those under 20 years of age. After the age of 20 there is no such enormous disproportion in the production of lunacy. It is undoubtedly most fre- quent between the ages of 35 and 55. Speaking generally, therefore, insanity in its worst forms is not a disease of youth or puberty, but of middle and advanced life. Slight attacks of nervous and mental de- rangement, however, that do not require asylum treatment, are by no means uncommon in those predisposed to the neuroses at the earlier ages, especially in the female sex ; and if the general health and strength and nutrition are poor, puberty is liable to cause neurotic symptoms in those cases. Such symptoms, if there is an inherited predisposition to insanity, should by no means be despised. They may develop into actual insanity at a later period. For the production of decided insanity requiring asylum treatment at the age of puberty, we must, as I said, have a strong neurotic predisposition, as well as the advent of the repro- ductive era and the changes it brings along with it. I have scarcely ever met with a case without this. Other affections of the nervous centres are very apt to appear at this period of life, notably the two great derangements of the motor centres, epilepsy and chorea. The motor centres are, no doubt, more unstable and easily upset in their working in youth than either the mental, sensory, or trophic centres. Infantile convulsions are the nervous disease of infancy. I believe that if there is a hereditary predisposition to any neurosis whatever in infancy, it most frequently shows itself in a special tendency to infantile convulsions during dentition. We find that the majority of cases of epilepsy and chorea in the female begin at the period of puberty. The insanity of puberty in both sexes is characterized especially by motor restlessness. Such patients never sit down by night or day, and never cease moving. There is noisy and violent action, sometimes irregular movements, or, in the few melancholic forms and melancholic stages of the maniacal cases, cataleptic rigidity. The mental symptoms consist most frequently of a kind of incoherent delirium rather than any fixed delusional state. In boys, the beginning of an attack is frequently ushered in by a disturb- ance in the emotional condition, dislikes to parents or brothers or sisters expressed in a violent, open way; there is irrational dislike to, and avoidance of, the opposite sex. The manner of a grown-up man is assumed, and an offensive "forwardness" of air and demeanor. This soon passes into maniacal delirium, which, however, is not apt to last long. It alternates with periods of sanity, and even with stages of depression. This is one of the most characteristic cases of the early insanity of puberty I have met with. I 'have seen others presenting the same pecu- liar symptoms : K. P., set. 11J, of an active and cheerful disposition, and a bright boy at school. His parents were poor, and he was brought up in a poor part 374 INSANITIES OF PUBERTY AND ADOLESCENCE. of the town. His mother had an attack of puerperal insanity (mania) after the birth of a child born before K. P., and another attack of ordi- nary acute delirious mania after he had been sent to the asylum, from both of which she recovered. He has an elder brother who, at the age of nineteen, had an attack of acute adolescent insanity (mania), and became demented, and is now in the asylum. There was no exciting cause of the boy's illness. He caught a feverish cold, and then became exalted in mind, singing continuously, clinging to his mother, saying he was going to heaven. This continued all day, but at night he slept twelve hours, and he took his food as usual. When sent to the asylum there was a very peculiar mixture of mental exaltation and depression present. He went on all the time singing joyful hymns in lively tunes, but in a voice as if crying. He would not answer questions or take any notice of anything about him, and could not be made to attend to anything any more than if he had been in a condition of trance. His whole condition was one of almost mental automatism, and as he sang he would rock himself, and keep time rhythmically with his hands and body. If anyone put their arms round him, he would cuddle up to them, and in a child's whining voice sing, "Tak me to ma mammy. Oh, my bonny mammy, my bonny mammy; come to me, mammy. Have mercy on me," etc., over and over again, in a rhythmical way; and if his eyes were shut and covered up he would go right off to sleep. The moment he awoke, the singing would begin. If he were much interfered with, he would shout and resist in a sort of unconscious way. He was poorly nourished and weak in body. He was sent out in the open air much, and was ordered a large quantity of milk and cod-liver oil emulsion. In about seven days the state of delirium passed off, and he got quite well mentally. His father took him home in three weeks, but he got into precisely the same state again on finding his mother insane at home and unable to speak to him. His mother was taken to the asylum, and he took the delusion that his father, too, was dead and gone. In about a fortnight he passed out of the delirium, and became quite cheerful and active. Just four weeks and two days after his second admission, he complained first of toothache, and then almost immediately became very excited, and said he could not see, sobbed, shouted, and was with diffi- culty restrained from throwing himself about. The symptoms were more those of ordinary acute mania, but with some of the former delusions, automatism, and facility for sleeping. This attack lasted for a few days only. He then remained well for exactly four months, and then had another attack, preceded by dilatation of the pupils and dimness of vision. The attack lasted for three days. He then got well again, but in another month to a day he got excited and emotional again. Though his face looked sad, and his voice was that of weeping, he never shed tears. This, the fifth, was the last attack he had ; after that he kept well, was sent home, and has now been there for more than a year. During the whole of the time he was in the asylum he was getting stronger and fatter, and was a well-nourished, cheerful boy, with no peculiarities what- ever, when he left. The chief features of this case were (1) the suddenness of the coming on of the mental attacks, without external cause ; (2) the curious auto- INSANITIES OF PUBERTY AND ADOLESCENCE. 375 matic delirious character of them, the mixture of exalted feeling with de- pression, and the impossibility of rousing his attention to anything outside of him ; (3) the way in which he went off to sleep when his eyes were closed and an arm was put round him, in both these respects resembling hypnotism ; (4) the repetition of the attacks in irregular monthly periods ; (5) his complete recovery at last. I look on such a case as an example of the evolution of a new function, that of generation, upsetting the convolutional working of a brain strongly predisposed by heredity to insanity. The physiological problem solving in the brain at this time seemed to be Shall the organism have power to reproduce itself? or shall it die in its highest function (mentalization) in the process of the evolution of the power to reproduce ? His elder brother had been attacked with insanity, not at puberty, but during adolescence, at the age of nineteen. He had at first exhibited a good many cataleptic symptoms, a motor automatic condition, just as K. P. had many mental automatic symptoms. In each case the " higher centre" of volition was powerless. The brother, after being maniacal for about two years in periodic intervals, has sunk into dementia. In him nature has stopped the reproduction of the species. The treatment I look on as an attempt so to strengthen the vital forces and the nutrition of the organism, that it shall pass through the whole period of the evolution of the new function without undergoing the risk of the destruction of all the higher mental faculties. K. P.'s case was no doubt in the very earliest stage of puberty, and, indeed, in some of its mental characters partook of some of the charac- teristics of the delirium of childhood. ADOLESCENCE. The mental disturbance characteristic of this period is closely allied to that which occurs at puberty. It occurs later, between the ages of eighteen and twenty-five, notably between twenty and twenty- five, when the function of reproduction is attaining its full development and the body is arriving at its full growth. That there is such an era in life physiologically is sufficiently proved by the existence in all languages of a word to signify the same thing as our " adolescence." I cannot hope to change the accepted meaning of the present nomenclature, but I would, if I could, distinguish between puberty and adolescence in this way I should restrict puberty, as i's now done when the term is used in a scien- tific and physiological sense, to the initial development of the function of reproduction, and to its first appearance as an energy of the organism ; while I should use adolescence to denote the whole period of twelve years from the first evolution up to the full perfection of the reproductive energy, when the bones are finally consolidated, and the full growth of the beard and the sexual hair takes place, and there occurs the perfect assumption of the manly form in the male sex, and the full development of the adipose tissue and the mammae gives the female form its perfect grace of contour. Dr. Mathews Duncan has proved statistically that in the female sex " the climax of initial fecundity," which may be taken as proof of full development, " is about the age of twenty -five years." 1 This may be assumed to be the case for both sexes. 1 Fecundity, Fertility, and Sterility, 2d ed., p. 33. 876 INSANITIES OF PUBERTY AXD ADOLESCENCE. Looked at from a psychological point of view, it can scarcely be denied by anyone that the later years of adolescence are far more important than the first. For years after puberty boys and girls are still boy? and girls in mind, but as a physiological fact the female sex attains its full bodily development first. At twenty-one the great majority of that sex have attained perfect physiological development, and Duncan's statistics show that their initial fecundity is then almost at it* climax. But this is not so in the male sex. The growth of the beard and the form of the body do not reach full development in that sex on an average till the age of twenty-five. Mentally the difference is still more marked. The subtle but profound mental influences of adolescence have usually reached their full maturity in women three or four years before men. 1 A careful study of human nature will soon show any observer that the period of adolescence in this sense is a most momentous one. The mental change that takes place from eighteen to twenty-five is incomparably more important, and I think more interesting psychologically, too. than that which occurs between fourteen and eighteen. The psychological change at puberty is, no doubt great from childhood: but it is inchoate and nascent : it wants precision and conscious power : its emotionalism is utterly spasmodic and childish : its sentiment wants tenderness, and its ambitions and longings are mere castle-building in the air. At adolescence in the male sex life first begins to look serious, both from the emotional side and in action. It is then only that childish things are put away. For the first time is literature, in any correct sense, appreciated. Poetry, not even understood before, now becomes a passion, at least certain kinds of poetry. Xot that the highest kind of literature is reached. No adolescent ever really appreciated, or even thoroughly liked. Shakespeare. That is reserved for full manhood. The kind of novel that is enjoyed is always a good test of the mental and emotional development. The boy enjoys Ballantyne and Marry at : G. P. R. James begins to have a dim meaning to the youth : at puberty the adolescent takes to Scott, Dickens, and Miss Austin : while only the man enjoys and understands Shakespeare. George Eliot, and Thackeray. Go into a university and watch the demeanor of the first and fourth year's man. if anyone has any doubt as to the immeasurable distance between puberty and adolescence. There seems to be a great gulf fixed between them. The fourth year's man treats his junior not as a mere junior, but as of a different and inferior species. He never speaks to him if he can help it : he would no more room with him than he would with a baby in arms. Watch the two in the presence of the opposite sex. Their behavior is quite different. In the one case you see mere shyness, that breaks out into rollicking fun the moment a real acquaintance is formed: in the other there is real sexual egoism, that most painful pleasure that consists of the half unconscious organic feeling that each person of one sex is an object of the most intense interest to each person of the opposite sex about the same age. The real events and possibilities of the future are reflected in vague and dreamlike emotions and longings, that have much bliss in them, but not a little, too. of seriousness and diffi- 1 See Edinburgh Medical Journal, July, 1879, "The Study of Mental Diseases,'' by the author. INSANITIES OF PUBERTY AND ADOLESCENCE. 377 culty. The adolescent feels instinctively that he has now entered a new country, the face of which he does not know, but yet that is full of possi- bility of good and happiness for him. He has a craving, too, for action of some sort not merely the football action of the boy, but something of more serious import. Longfellow's youth that vaguely cried "Excelsior" was evidently at this stage of life. His reasoning faculty first gets some backbone at this period. His emotional nature acquires for the first time a leaning towards the other sex that quite swallows up the former emo- tions. It is not yet at all under his control, fixed or definite in its aims. His sense of the seriousness and responsibility of life may be said to awake then for the first time in a real sense. The first sense of right and wrong and of duty becomes then more active instead of passive. He has yearnings after the good, and is capable of an intense hatred and scorn of evil which he could not have experienced before. But it is in the female sex that the period of adolescence has attracted most attention, especially among those psychological students and deline- ators of character, the novelists of the day. As physicians, we know that it is only then that hysteria, migraine, and the graver functional and reflex neuroses arise. As men of the world, we know that the love- making, the flirting, the engagements to marry, and the broken hearts of the adolescents are not really very serious affairs. The cataclasms of life do not happen then. We know that no artist ever painted, or no sculptor ever modelled, a Venus who had not passed adolescence. A very fine and most interesting study of adolescence in the female sex is, in my opinion, to be found in the Gwendolen Harleth of George Eliot's novel of Daniel Deronda. This authoress was by far the most acute and subtle psychologist of her time, and certainly the character I have men- tioned is most worthy of study by all physicians who look on mind as being in their field of study or sphere of action. From the time when, at the gaming-table, Gwendolen caught Deronda's eye, and was totally swayed in feeling and action by the presence of a person of the other sex whom she had never seen before : playing, not because she liked it or wished to win. but because he was looking on, all through the story till her marriage, there is a perfect picture of female adolescence. The subjective egoism tending towards objective dualism, the resolute action from instinct, and the setting at defiance of calculation and reason, the want of any definite desire to marry, while all her conduct tended to promote proposals, the selfishness as regards her relations, even her mother, and the organic craving to be admired, are all true to nature. Witness her state of mind when Grandcourt first appeared : " Hence Gwendolen had been all ear to Lord Brackenshaw's mode of accounting for Grandoourt's non-appearance ; and when he did arrive, no consciousness was more awake to the fact than hers, although she steadily avoided looking towards any point where he was likely to be. There should be no slightest shifting of angles to betray that it was of any consequence to her whether the much-talked-of Mr. Mallinger Grandcourt presented himself or not. And all the while the certainty that he was there made a distinct thread in her consciousc Again : " Gwendolen knew certain differences in the characters with which she wa con- cerned as birds know climate and weathr I 378 INSANITIES OF PUBERTY AND ADOLESCENCE. The sentimentality of this period of life is well illustrated when Gwen- dolen says : " ' I never saw a married woman who had her own way.' ' What should you like to do?' said Alex, quite guilelessly, and in real anxiety. [He was an adolescent just entering on the period.] ' Oh, I don't know ! Go to the North Pole, or ride steeple- chases, or go to be a queen in the ball, like Lady Hester Stanhope,' said Gwendolen nightly. ' You don't mean you would never be married.' ' No, I didn't say that. Only, when I married, I should not do as other women do.' " The inchoate religious sentiment, as a psychological faculty contending with the egoism, is thus brought out : " "What she unwillingly recognized, and would have been glad for others to be un- aware of, was that liability of hers to fits of spiritual dread. . . . She was ashamed and frightened as at what might happen again, in remembering her tremor on sud- denly finding herself alone . . . Solitude in any wide scene impressed her with an undefined feeling of immeasurable existence aloof from her, in the midst of which she was helplessly incapable of asserting herself. With human ears and eyes about her, she had always hitherto recovered her confidence, and felt the possibility of win- ning empire." The selfishness and craving for notice are thus hit off: " I like to differ from everybody. I think it is stupid to agree." " Her thoughts never dwelt on marriage as the fulfilment of her ambition. . . . Her observation of matrimony had induced her to think it rather a dreary state, in which a woman could not do as she liked, had more children than were desirable, was consequently dull, and became irrevocably immersed in humdrum. Of course, mar- riage was social promotion. She could not look forward to a single life. . . . She meant to do what was pleasant to herself in a striking manner; or rather, whatever she could do so as to strike others with admiration, and get in that way a more ardent sense of living, seemed pleasant to her fancy." But extracts merely spoil the whole picture, which is one that is in perfect accord with the facts of nature, drawn by a consummate artist. It is one of the most perfect psychological studies with which I am acquainted. It seems like passing from the poetry of science to Dryasdust's details, to descend from George Eliot's word-pictures to the details of physio- logical fact and speculation that underlie all this charming maiden's mental constitution. I think most medical men of extensive observation would agree with me, that the incompleteness of those mental tokens of merely developing womanhood and manhood during the period of adoles- cence do indicate that the conditions under which the reproduction of the species takes place should be deferred till adolescence has passed. The love-making of adolescence is not the serious matter it should be, as Gwendolen's history well shows; and, therefore, the full physiological and psychological conditions for dualism not being there, it should not be encouraged. All serious love-making, engagements to marry, too free intercourse with the other six, too much dancing, too much going into society, merely tend to force on the full development, like young plants in a hothouse, with the result that the flowers and fruits have a tinge of artificialness, do not last, do not stand the same tear and wear. A young man who marries before his beard is fully grown breaks a law of nature and sins against posterity. A girl who gets engaged while in Gwen- dolen's state of mind is not likely to derive all the happiness in marriage INSANITIES OF PUBERTY AND ADOLESCENCE. 379 of which she is capable. It follows, therefore and most members of our profession would, I think, agree with me that sexual intercourse should not be indulged in till after adolescence. The period of adolescence is very liable to those psychological cata- clasms in weak brains, attacks of mania, that have a special relationship to the function of reproduction. Especially it seems to me that the periodicity and remission of the nisus generativus in both sexes, and the menstrual periodicity which accompanies it in females, are reflected in a periodicity and tendency to remission in the insanity that occurs during adolescence. Passing now from the physiological and psychological characteristics of adolescence to the forms of mental disease that prevail then, the fol- lowing was a very severe case of the insanity of adolescence terminating in recovery : K. Q., set. 23, a student, who worked hard, who had a neurotic heredity, whose life had been sedentary, and whose bodily health and nutrition had run down. It was feared, too, he had been given to the habit of masturbation. He had been working extra hard to pass an examination, when suddenly, without any other exciting cause, he became morbidly exalted, lost his power of sleep, got restless, talkative, violent, and unmanageable at home. Within four days he had to be sent to the asylum. He then labored under acute, almost delirious, mania. He was exalted, giving incoherent descriptions of metaphysical speculations and mental problems. There was a great deal of the sexual element running through his incoherence and his speculations. His temperature was 100.1 ; his pulse 84, weak; his weight eleven stone twelve pounds. He was kept outside nearly all day in charge of two good attendants, though most violent ; he was compelled to take four custards a day, each con- taining four eggs and a pint and a half of milk, in addition to any ordi- nary food he could be got to take. He was treated with warm baths at night, with cold to his head, and large doses of bromide and iodide of potassium combined while the temperature was high. He slept little, and in spite of the enormous quantity of nourishment taken he fell off in flesh and strength. Contrary to my usual custom in adolescent cases, I added a considerable quantity of port wine to his diet, as he looked at times so exhausted. In the first six weeks of his stay in the asylum he lost two stone in weight. All kinds of sedatives were tried temporarily in vain. I thought he was going to die of exhaustion. He had a slight beginning of a hsematoma, which was blistered, and so stopped. The excitement was paroxysmal and recurrent in its intensity, though he was never free from it. After about two months the intensity of the maniacal condition began to abate, and he passed into what is to me a most anxious stage in these cases. His expression of face became enfeebled looking, his habits dirty, he masturbated badly, and his whole mental state sug- gested dementia rather than either mania or recovery. One cannot pay sufficient attention to the treatment of such symptoms in that stage. The nourishment was made a little more stimulating by strong soups, in addi- tion to the milk and eggs. He got fresh vegetables, cod-liver oil, with the hypophosphites, and strychnine and iron. He was narrowly watched and well nursed, and much moral treatment adopted to rouse and interest him. It was in truth a toss up between recovery and dementia, between 380 INSANITIES OF PUBERTY AND ADOLESCENCE. mental life and mental death. Fortunately the recuperative power of his brain and constitution prevailed, he slowly picked up flesh, and his beard and whiskers began to sprout I have much faith in adolescent recoveries when the beard has grown coincidently with recovery and his weight increased fast and steadily, until in six months from the commencement of his illness he was quite well in mind, and strong and stout in body, weighing thirteen stones. This was one of only about six patients that I have seen where recovery took place after a hsematoma had formed or even been threatened in any degree. Such cases are not always so fortunate. Lives that looked full of promise are sometimes blasted on the threshold of what seem most bril- liant careers, as in the following case of K. R., set. 20. Heredity very neurotic, mother being very nervous, aunt insane, and father drunken. He had been a most brilliant and successful student, and he had poetic gifts that made his friends look forward for his future with much enthu- siasm. His illness came on when he was reading hard, sleeping little, supporting himself by teaching, and also perhaps further exhausting his energy by illicit sexual indulgence. Without any proximate cause he became much exalted in mind and much excited, sleepless, and fell ofl' his food. The common remedy of enormous doses of morphia was resorted to. He got sleep, but was no better for it, and after it would take no food whatever. When he came to the asylum he was quite incoherent, raving about religion and women. His tongue and lips were dry; his temperature 99 ; pulse 144, small and thready ; and his general strength small, though his maniacal muscular energy was great. I could get him to take no food, so at once fed him with the stomach-pump. He had to be put in the padded room at night on account of his delirious violence, but was taken out each day into the fresh air by three good attendants. He began to take his food after a few days, but remained acutely excited for a fortnight. Then there was a remission, but the mania came on again, as indeed it did all through his case, by spurts. In about three months he began to be more coherent, and wrote some poetry. As it illustrates the common mixture of religious and sexual emotion in this and most of those cases very graphically, I quote some of it here : A SOLEMN ANTHEM IN CELEBRATION OF THE NEW JERUSALEM. O, Rosaly, my warm and panting girl, Just image to yourself the gates of pearl ! The angels sitting in illustrious row, Kissing their hands to the Holy Ghost below, That glorious unimagined mystery, The very hot and lovely Trinity, Afar they see the lake of crystal shine, Filled with the juice of maidens' paps divine. They hear the sappy sound of neighboring love And kisses, sacred as the brooding dove. They look unto the Great White Throne and laugh. Christ plies the Virgin with luxurious chaff; Jehovah feels the Queen of Sheba's beauty, And refers to the loveliness of Judy. The Devil reads the Sermon on the Mount, And adds a little on his own account. And so they sing their wicked songs together, While God in anger frowns upon the weather. INSANITIES OF PUBERTY AND ADOLESCENCE. 381 His bodily health and strength gradually improved, his beard and whiskers sprouted in great luxuriance, but his mental power did not return. He continued to write poetry, but it got more and more inco- herent. He called himself at times "Jesus Christ, Prince Algernon Swinburne," though this was scarcely a fixed delusion. He had been an intense admirer and great reader of Swinburne's poems, and, as in the specimen given above, all his insane poems were influenced by the rhythm and by the ideas of that author. The treatment adopted was the same as in the previous case, but to no avail as regards his recovery. The change to another asylum was tried, but did not rouse him. He sunk into dementia in about two years. The following patient was not a head-worker: K. S., aet. 21. A quiet, steady, and intelligent fisherman ; stout, ruddy, and strong in body. He came of one of the families of the fishing village of Newhaven, that have intermarried for many generations, and in many of which now there is an enormous amount of insanity or epilepsy. I know one such family where four girls in succession, cousins of K. S., became subject to epilepsy and then became insane. If any proof were needed of the supreme importance of hereditary influences in the production of mental diseases and epilepsy, and the small influence of healthy conditions of life in counteracting these hereditary influences in many instances, I would point to the village of Newhaven. The people are well-fed fisher folks. They are robust and handsome. Most of the "bonny fishwives" that are so picturesque an element in the street scenes and street sounds of Edinburgh belong to this village. The life they lead is a natural out- door one, and yet insanity is more common among them than in any community of a similar size I know. That fact along with others, noto- riously the frequency of insanity among the old families of the Society of Friends, the most self-controlled and virtuous of all religious sects, is a complete answer to those who say that mental diseases are mostly due to drink and vice and the manifestly bad and unnatural conditions of modern town life. But to return to K. S. He at first behaved as if something was "preying on his mind," and when questioned could only assign as a cause a common dispute in a boat. This was, no doubt, the melancholic prelude to the attack. Then he became elevated, and then maniacal and violent. This lasted for about a week, and he appeared to be well. In a few weeks he again became maniacal, and was sent to the asylum. His bodily health seemed absolutely perfect in all respects. He was a fine, fresh, ruddy young son of the sea. He was set to hard work in the gar- den, and in ten days became rational and quiet, and he has never had another attack for now three years. I noticed that during three months he was in the asylum his beard and whiskers, which were nascent on admission, grew out full and strong, so that, though he came in smooth- faced, he left a bearded man. This was a case in which there seemed absolutely no exciting cause whatever for the attack but the completion of the period of adolescence. The following case was one that made a complete and permanent recovery after being over a year very ill indeed : K. T., set. 22. Mother had had puerperal mania. At eighteen he had an attack of acute mania, which lasted for two months, and was treated at home. 382 INSANITIES OF PUBERTY AND ADOLESCENCE. Since then he has kept well, and followed an outdoor occupation, till his present attack. Before corning to the asylum he had become maniacal again and most violent, the attack beginning with elevation, talkativeness, imprudent conduct, disrespect to his father, and generally such behavior as looked like mere badness. Many such cases that never reach the acutely maniacal stage are put down to vice and drunkenness. He was sent to the country with an attendant, and seemed to recover in a fort- night. He then returned home, but in a month from the beginning of the second attack he became maniacal again, and was sent to the asylum. While there he had five violent attacks of acute mania, at pretty regular intervals over twelve months, and then recovered. One of these attacks was longer than the rest, and was attended with considerable emaciation, dirty habits, and demented expression of face, and I was afraid of dementia, but the treatment I have described was most energetically per- sisted in, and he recovered. It is a very interesting study to watch such a case from day to day and week to week. I consider that if the daily loss of flesh, which will occur for perhaps the first few weeks and during the acute and sleepless stage, is checked soon, and the patient ceases to lose weight, that it is a good sign. I encourage the attendants to feel in those cases that they are fighting the disease with milk and eggs and fresh air, and to interest them in the case by letting them weigh their patients every few days. A good attendant will show a lively interest in the contest with the disease, and will feel a sense of personal elation or defeat as weight is gained or lost. After dementia has set in, body weight may be gained with no corresponding mental improvement ; but a gain in weight within the first six months, or even the first year, means that recovery is probably going to take place ; and within that time everything that tends towards increased body weight tends towards recovery. The last case I shall refer to is one where recovery did not take place, but dementia resulted. K. V., set. 16. Has an aunt in the asylum. Had been a month ill before admission. He was excited, noisy, shouting, and dancing about. That was in 1878. For four years he was subject to attacks of acute maniacal excitement at intervals of a few months. In the first year they were very acute. This is a general rule. My expe- rience is that the first attack or the second is apt to be the worst. In K. V.'s case the attacks got less acute after the first year, but in the in- tervals between the attacks he was less sane. A clouding process over his mind went on, each attack leaving him rather more enfeebled than the last. But he was once so well that he was tried at home for a short time. He gradually sunk into secondary dementia, with rare and occasional spurts of restlessness and mild maniacal excitement at irregular intervals a type of the healthy chronic lunatic that forms half the population of most asylums, and he is likely to live for many years. He can work in the garden, can answer questions, sleeps well, is not uncleanly in his habits, mingles in the asylum amusements, but all his "higher nature" is gone. He cares little for his relations. His joys and sorrows are very mild. He has no interest in life, no ambition, no great sense of right or wrong, no volition in any higher sense, and no religious instinct. INSANITIES OF PUBEKTY AND ADOLESCENCE. 383 TREATMENT OF THE INSANITY OF ADOLESCENCE. The treatment I have lately adopted for such cases is founded on physiological considera- tions. The completion of the period of adolescence is in both sexes accompanied by a considerable deposit of adipose tissue, by an overplus of strength and activity, and by a state of general good nourishment of the body. To attain to this normal condition of body should undoubtedly be our aim in treating all cases of mental disease at this period. It always seemed to me that there were two things that constantly worked the other way, and that I had to contend against in their treatment. These were the general brain excitability and the morbid strength, and often perversion, of the generative nisus. The one tended to mania, sleeplessness, purposeless motor action, thinness, and exhaustion ; the other to erotic trains of thought, sexual excitement, and masturbation. I found that inaction, reading, indoor life and amusements increased the one, and novel-reading, solitariness, and long hours in bed aggravated the other, while animal food and alcoholic stimulants gave increased strength to both morbid tendencies. I therefore put my patients to active exercise in the open air for as many hours a day as possible, walking, digging in the garden, wheeling barrows ; I give them shower- baths in the morning when the weather is suitable and they are strong enough, and I encourage active muscular exercise in every way. Athletic games of all sorts in the open air are certainly good so far as they go. I place great reliance on the diet. Milk in large quantity, and as often in the day as possible, bread, porridge, and broth are the staple articles of food for such patients here. My friend Dr. Keith, of this city, was the first to direct my attention to the advantage of a light, farinaceous, and milk diet in another class of cases, and my experience is strongly in favor of his views. The patients may have some fish, or fowl, or eggs, but in reality milk is the most important means of treatment. I seldom give such cases alcoholic stimulants. I give to all such patients who can take and assimilate it easily an emulsion of cod-liver oil, hypophosphite of lime, and pepsine, made and flavored in such a way that it resembles cream. I find very few indeed who cannot take this. Beyond this, an occasional bitter tonic, with sometimes a chalybeate or some of the new compound syrups of the phosphates, are about all the medicines I give. The effect of this diet, regimen, and treatment is very marked in the majority of cases. No doubt during the first part of the attack the patients may lose weight while the excitement is in its most acute stage ; but they soon begin to gain weight, and my prognosis is always favorable when I find a patient beginning to gain weight within a reasonable time, say six months or so. I have had patients who, in spite of very sharp excitement indeed and much sleeplessness, gained weight under this treat- ment. It seems to me that the process of fattening such a patient, and the conditions under which it takes place, are antagonistic to the disease and its results. I have known the stopping of the cod-liver oil to be followed at once by a loss or diminished gain in weight, and its resump- tion to be followed by the former rate of increase. If a young man or woman suffering under the insanity of adolescence is found to gain one or two pounds a week within the first three months, I look on him as quite safe. It is common to gain a stone in a month. 384 INSANITIES OF PUBERTY AND ADOLESCENCE. I have now pursued this plan of treatment long enough to yield results that can be relied on, and I believe that more of my patients recover than before I adopted it. They recover sooner, and their recoveries are more reliable and permanent. Even in the case of those who sink into de- mentia, I think they do so more quietly and with less of the element of chronic mania than under a flesh diet. It is, I think, certain that the habit of masturbation, which is so frequent and so deleterious in such cases, is less practised by patients on this diet, and, when practised, is less damaging to brain function, and takes less hold on them. Lastly, in connection with this subject, I would say a word about pro- phylaxis in children with a strong neurotic inheritance. My experience is that the children who have the most neurotic temperaments and dia- theses, and who show the greatest tendencies to instability of brain, are, as a rule, flesh-eaters, having a craving for animal food too often and in too great quantities. I have found also a large proportion of the adoles- cent insane had been flesh-eaters, consuming and having a craving for much animal food. It is in such boys that the habit of masturbation is most apt to be acquired, and, when acquired, produces such a fascination and a craving that it may ruin the bodily and mental powers. I have seen a change of diet to milk, fish, and farinaceous food produce a marked improvement in regard to the nervous irritability of such children. And in such children I thoroughly agree with Dr. Keith, who in Edinburgh for many years has preached an anti-flesh crusade in the bringing up of children up to eight or ten years of age. I believe that by a proper diet and regimen, more than in any other way, we can fight against and counteract inherited neurotic tendencies in children, and tide them safely over the periods of puberty and adolescence. The following is a statistical and clinical inquiry into the subject of the insanity of adolescence. For this inquiry I took for the period of five years and a quarter (from 1874 till the end of the first quarter of 1879) all the cases that were admitted into the Royal Edinburgh Asylum. They amounted to 1796 917 men and 879 women. Of these, 320 were between the ages of 14 and 25, viz. : 195 males and 125 females. Now, if my object had merely been to arrange those 320 patients each in a classification of symptoms, it would have been simple enough : so many with exaltation under "Mania," so many with depression under "Melancholia," etc. That was done, but a great deal more informa- tion must be expiscated about each case if we are to arrange them in clinical or physiological groups, and especially if we are to have any light thrown on the question " Did adolescence influence the mental symptoms present in those cases?" We must ask and answer the fol- lowing inquiries : "In how many cases did the disease exist, before the age of 14, or was of a kind with which adolescence could have nothing to do ?" I found I had to deduct 90 such cases, or about one-third of the 320 who had been mentally defective or epileptic from birth, or very early ages, or labored under organic disease, or in whom the disease came on in nursing or childbirth, leaving 230 in whom it was possible for puberty or adolescence to cause or influence the disease. The next inquiry naturally was " If 230 occurred in the twelve years between the ages of 14 and 25, is that number greater or less than is INSANITIES OF PUBERTY AND ADOLESCENCE. 385 found in the same number of years at other ages?" I find it to be far more than between 2 and 14, but less (10 per cent.) than between 30 and 40. At this particular age, either from adolescence or some other cause, it is clear that there arises a liability to insanity which did not before exist, but which does not cease when adolescence is past. The next query was this : " Taking this long period of twelve years, is there any special liability during any of the years of that time?" " Does it arise at puberty, or towards the completion of the period of adolescence?" A glance at the numbers who became insane in each of the twelve years shows that the first two, that is the 14th and 15th, were especially exempt, only producing one case each ; and the next two, the 16th and 17th, also very few (22). Now the fact that there only occurred in those four years of life 24 cases out of about 1800 in all (230 of them being adolescents and healthy up to that period), does show clearly that the first onset of the reproductive function is not a dangerous one as re- gards liability to insanity. The next three the 18th, 19th, and 20th are still low, producing only 49 cases, or an average of 16 in each year. In those three years, while puberty has occurred in nearly every individual of both sexes, yet adolescence has not been completed in many of them. It was in the next five years, from the 21st to the 25th, that the vast majority of the cases occurred,' viz. : 157 of the 230, or an average of 31 in each year as compared with an average of 8 for each of the first five years. At 14 and 15 the liability to insanity was practically nil, from 21 to 25 it was very great. In fact, a comparison with the liability at other ages during the past five years in the admissions to the asylum shows that there is no period of life in which uncomplicated insanity occurs more frequently than during the completion of the physiological era of adolescence, from 21 to 25. It must be kept in mind that I am not now speaking of the numbers becoming insane in proportion to the number of the general population alive at any particular period. Comparing the two sexes, the total numbers and relative proportion of females are smaller in the adolescent period than at later periods of life. Adolescence does not appear to be so powerful an upsetter of mental equilibrium in women as in men. Having elucidated these points, we come to the question as to what mental symptoms these adolescents suffered from, and if those symptoms were in any way peculiar ? While investigating this, I found the com- plications of marriage, childbearing, and lactation in the females so common after the age of 21, that it was difficult to compare them with the males. I therefore made 21 the limit of age for them. This reduced their numbers to 40, making, with the 140 males, 180. The first fact of importance is, that there were only 40 cases in which the symptoms present were classed as states of mental depression or melancholia, while the rest were cases of exaltation or mania. Now, the significance of this proportion is only seen by comparison. During the past five years in the asylum there have been admitted two cases of un- complicated mania to one of melancholia (849 to 439), whereas among the adolescents it was 3| to 1 (140 to 40). And if we compare them with those at more advanced ages, e.g., women at the climacteric period, 25 386 INSANITIES OF PUBERTY AND ADOLESCENCE. the proportion of mania to melancholia is reversed, there being only one case of the former to If of the latter. The proportion of states of exaltation of mind or mania, therefore, is much greater as compared with those of melancholia among the adolescent insane than among the insane at all ages, this excess being still more marked when compared with the cases of mental disease occurring at the climacteric period of life. The next inquiry was " What was the character of the mania?" I found that it had several well-marked characteristics. It was, in the first place, often of a very acute, though seldom of a delirious type ; in the second place, it was mostly of short duration, the patients getting soon apparently quite well ; in the third place, the patients were subject to constant relapses. Out of the 180 cases, 118, or 66 per cent., had such intermissions of sanity with subsequent relapses. This tendency to short, sharp attacks, with intermissions of more perfect sanity than occurs in most other kinds of mental disease, with relapses occurring one, two, three, four, and five times, and even more frequently, before recovery or dementia finally takes place, may be taken to be especially characteristic of this insanity of adolescence. In many of them, as the maniacal attacks passed off, there was a slight tendency to melancholia, a sort of reaction no doubt. This was noticed in 62 cases. This relapsing character with the tendency towards depression brings adolescent insanity into relation- ship with folie circulaire. The real cause of the remissional character of both is no doubt the periodicity of the generative power and desire in their greatest intensity. Another well-marked characteristic was this, that a hereditary predis- position to mental disease, or at least to some of the neuroses, was present in 77 of the 180, or in 45 per cent, of the whole number. It is very difficult to get family histories of insanity in most cases, and you may multiply by two those you get, if you want an approach to the truth. The proportion of hereditary predisposition in the asylum, as recorded in our case-books, is only 23 per cent, as compared with the 45 per cent, among the adolescents, in whose cases no special pains had been taken to ascertain family histories. I observed a still more striking fact in regard to the heredity of the insanity of adolescents. I happened to have a personal knowledge of the history of the cases or of the families in fifteen of the cases, and in twelve of these there was a hereditary predis- position to the neuroses. The insanity of adolescence is therefore pre- disposed to in most cases by a nervous heredity, being one of the most hereditary of all forms of mental disease. Another marked character of the mania was that the ideas, emotions, speech, and conduct were all strongly tinctured by the mental charac- teristics of adolescence in an exaggerated or morbid way. That per- version of the sexual act, the habit of masturbation, was very common, probably existing in over 50 per cent, of the cases, aggravating the symptoms, and diminishing the chances of recovery. In the females hysterical symptoms were common, such as mock modesty, simulated pains, and a desire to attract attention. In the males heroic notions, an imitation of manly airs and manners, an obstrusive pugnaciousness, and sometimes a morbid sentimentality were present. In almost all the cases INSANITIES OF PUBERTY AND ADOLESCENCE. 387 the physical appearance of the males was boyish when the attack com- menced ; and most of the females were girlish rather than womanly in contour. As regards the results of treatment in those cases, 93 were discharged recovered, or 51 per cent. ; but then 40 were removed home or to other institutions relieved, many of whom would have been likely to recover ultimately. I only know of 26 of the 180 who became incurable. In- sanity occurring at the adolescent period is, therefore, a very curable disorder, as compared with many other forms, though not so curable as some others, e. g., puerperal insanity. Just before recovery, in almost all the cases which did get well, signs of physiological manhood appeared, the beard growing, the form expanding, the weight increasing. When- ever I see those signs, accompanied by mental improvement, I am in- clined to give a favorable prognosis. The mortality was very low, only three of the 180 cases having died. LECTURE XVII. CLIMACTEKIC INSANITY SENILE INSANITY. As unstable brains are apt in certain cases to be upset in their mental functions by the oncoming of the reproductive power and the sexual desire at the periods of puberty and adolescence, so they are apt to suffer as those great powers of the organism pass away at the climacteric period. An animal has functionally and physiologically three distinct periods of existence (1) when its life is dependent on that of its mother before birth ; (2) when it lives independently, but cannot reproduce itself, before puberty and after the climacteric ; and (3) when it both lives and can reproduce. The mental function is non-existent in the first period, more or less imperfect in the second, and fully developed in an ideal sense only in the third. At the period of the climacteric there is unquestionably a normal mental change in both sexes. The sexual desire invariably weakens in its intensity or ceases altogether, and with it the affectiveness changes in its object and greatest intensity from the mate to the progeny, losing its imaginative force, its fire, and its impulsiveness. Poetry and love tales then cease to have the power "to set the brain on fire." Action of all kinds ceases to be so pleasurable for its own sake as it has been before. Much of "the go is out" of the person. The instinctive feeling of difference of sex, and all that it implies, which has been all- pervading before, now lessens visibly. The subtle interest of the society of the other sex is less electric and overmastering. Along with these affective changes there are bodily changes too. The form alters, especially in women, and the expression of face changes, the ovaries shrivel, Peyer's patches lessen in bulk, and the spleen and lymphatic glands harden. The blood-forming and the blood-using processes slacken in speed, and the trophic energy in all the tissues is less intense in action. "Life becomes slower." in fact, mentally and physically. And as a result of this, after the climacteric has been safely passed, the organism is less liable to many diseases than it has been before. The real climacteric period in both sexes is never a definite fixed time, but usually extends over a year, or two, or three. The mere cessation of the function of menstruation in women does not necessarily fix definitely the mental and nutritional changes that mark the period. I have known a woman of fifty who had gone through the mental changes of the climacteric, yet in facial expression and in shape was post-climacteric, who had no sexual desire, yet was menstruating regularly; and, on the other hand, I have known many women of the same age in whom menstruation had ceased from forty to forty-six, who were yet quite shapely, amorous, and men- tally youthful. So the mental disease that accompanies the climacteric need not be quite coincident with the menopause, but may occur some CLIMACTERIC INSANITY. 389 time before or some time after that event. As a matter of fact, the ordinary sensory nervous symptoms that are connected with the climac- teric in women, viz., giddiness, flushings, flashes of light, uneasy organic sensations, usually precede the actual cessation of the menses rather than accompany it. A typical case of climacteric insanity begins by a loss of energizing power, bodily and mentally, of which the patient is rather supersensi- tively conscious. Her courage fails ; little things come to have the power of annoying her that she would have thought nothing of before. Groundless fears, which at first she knoAVS to be groundless, haunt her at times. And at this stage the sleep is apt to be dreamy and broken, the appetite for food is less intense, and the bowels costive. There is apt to be some falling off in freshness of the complexion and in looks generally. The skin often gets muddy, and more pigmented than usual. It is a trouble for her to go into company or to move about in public, and yet she has no restful feeling and no contentment or organic happiness. At the menstrual times all these things are much worse, and there is apt to be real depression of mind, weeping, with irritability of temper and sleeplessness. I have never yet met with a climacteric case in this early stage who did not feel much better in the open air than in the house. That is an indication of treatment and of prevention of further symptoms that I never fail to find useful. I have seen iron at this stage, too, do very much good; in fact, it seemed to act as a specific. But those symp- toms do not constitute insanity, though they are essentially mental dis- order. The next stage consists of more real ai.J continuous depression. The morbid fears assume a more intense character, though they are often still indefinite. The patient is quite sure some evil thing is going to happen to her, though she cannot tell what it is to be. The self-control is often lost, but much more frequently the patient is terrified that it is going to be lost. There are vague impulses towards suicide, sometimes towards hurting husband and children, and the existence of these add to the terror and intensify the depression. Such things are thought by the patient to be "so wrong," and she blames herself for them. A conscious loss of affection, or rather a loss of the pleasurable feeling that conscious affec- tion for husband and children gives, is a cause of the greatest distress. There is often a sort of organic repugnance to the husband and to his attentions. By this time all the usual sensory accompaniments of the climacteric have disappeared, or rather they have been transformed into the mental neurosis I am describing. There are no headaches, or giddi- ness, or flushings. But the trophic neuroses become aggravated all the time. The thinness, the flabbiness of muscle, the pigmentation of skin, get worse. There are* frequently skin irritations, and the patient picks and scratches her skin. The bowels are costive, the appetite gone, the sleep absent, and the capacity for work greatly lessened. In the worst cases, suicidal feelings are strong and attempts frequent, but they are rather apt to be feeble. The very loss of courage and vigor of will operates against any effectual attempts at suicide, however much the wish may be there. Hallucinations of hearing are frequent. This condition may pass into acute excited melancholia and exhaustion, and 390 CLIMACTERIC INSANITY. death ensue, or it may become a sort of chronic shy uselessness, or "paralysis of energy," or it may gradually pass away under proper treatment and conditions of life, and the woman become strong, cheerful, well-nourished, and useful, more "healthy" in a certain sense at all events than ever. The following is a case of climacteric insanity, of short duration but very acute form, and with an element of stupor. K. V., set. 46, of a cheerful and sociable disposition, and good habits, but with some heredity to insanity and the neuroses, a sister having been insane, and a child having died of hydrocephalus. My impression is that, of all the expressions of an heredity to insanity in childhood, hydrocephalus is, next to convulsions, the most common. The whole question of the transmission of neuroses to children by mothers who are then to all appearance healthy, and in whom any nervous disease is a mere potentiality, is very interesting, and stands in need of accurate observations. The weak and troublesome point of all studies of heredity is that they cannot be regarded as complete till all the subjects of them are dead. K. V. had over-exertion of body and anxiety of mind in nursing her husband and through his death, just as she was becoming irregular, this being the exciting cause of her attack. She became irreg- ular in her menstruation, but had not many of the usual sensory accom- paniments of the climacteric. My experience is that in the climacteric cases with a mental neurosis, the former are often enough absent. The one seems to come instead of the other. She never slept well after her husband's death. In about two months thereafter she became depressed, and suspicious that her neighbors had an ill-will to her and that everyone was against her. It is easy to see how a lone, neurotic widow, with a family to support, should take such ideas. But by and by she began to fancy that her friends put poison in her food ; no doubt this was the misjudged sensation of the pain of dyspepsia. Then she began to groan most of the time, and to cease to attend to her work, or to take an interest in anything, her whole mind being absorbed in her morbid thoughts. On being sent to the asylum, she picked up to some extent at once, exercising all the self-control she was capable of, the very unpalatableness of the situation rousing her. She was thin and dark-skinned, and had a dull, listless look. Her sensibility to pain was dulled, there being an element of mental stupor in her case. The tongue was furred and tremulous, and the bowels costive. Her pulse was 88, weak ; her temperature 99.3 ; and her weight only eight stone eight pounds. She was much depressed and confused, mistaking the identity of people about her. She slept very little at first. Her appetite was poor, and her notions of cleanliness and decency were meagre. She was ordered quinine and iron, warm baths, exercise in the fresh air, simple laxatives,'and proper supervision and nursing. In a fortnight she was sleeping better, in a month she was sleeping well. She took plenty of food, occupied herself in useful work, and her skin began to look clearer and more healthy. Her fears and delusions became vague, and with less influence on her demeanor. She would then take a good fit of crying, which did her good. In another month she had gained over a stone in weight, and was fairly convalescent, and being much needed at home, was sent there perhaps earlier than CLIMACTERIC INSANITY. 391 might otherwise have been desirable. The disease in such short cases has little tendency to recur. When she left she was getting the post- climacteric look. The following case is one in which the symptoms of climacteric insanity came on several years after the menopause, were never very acute, yet the woman has not got over them for two years. She is rational in conversation, and has no delusions, and her depression is by no means acute, but she is so absolutely devoid of initiative power and energy that she remains voluntarily in the asylum, and is quite unfit to do her work in life. K. "VV., set. 51, a widow, a healthy, cheerful, active woman, who had two children, and no heredity to insanity. About forty-five, so far as she remembers, she ceased to menstruate, this being accompanied by fearful headaches, feeling sometimes as if she would " go out of her mind." Those headaches continued more or less up to the onset of her present attack of melancholia, but she did not change in facial expression, and did not lose her shape, in fact did not exhibit the usual bodily signs of having passed the crisis, till the depression of mind began to appear. At fifty-one, without any cause, she became depressed in mind, nervous, anxious, and fearful. She gradually developed the delusion that her friends wished to take her life. She was sleepless, and once threatened to throw herself out of the window. She lost all hope and courage and interest in life. She got occasionally excited and lost her self-control, which was the cause of her being sent to the asylum, but during the two years she has been there she ne^er has shown any sign of excitement, except on one occasion slightly. She has simply been a dull, anxious, retiring person, morbidly fearful of giving offence, and having a dread on her that something fearful is going to happen to her. She has eaten and slept well. She does what she is told without interest. She has vague semi-delusional ideas that her friends are all dead, that the people here seem to be the same as her former friends, that the things and people about here are not real. She has those feelings, yet she does not really believe them. She has pains and numbnesses in her joints and her limbs, probably neurotic in origin. She eats well far more, she says, than she ever did before looks stout and well, sleeps well, and is muscularly strong, though not alert or active. She leads a dependent life, with no joy in it at all or no interest in anything, but with little intellectual impairment in the sense of dementia. She shows no sign of recovery and no sign of getting worse. Yet I think recovery perfectly possible in her case, for I have seen such cases recover after several years. She lives on a lower plane emotionally, and as to energy and spontaneity. She never laughs, but never cries, and never loses her temper. She has no pleasure in social intercourse, but she does not shun her fellows. This is to me just an ex- aggerated and morbid type of post-climacteric physiological and psycho- logical life. Some of the cases take a long time to recover. I never give up hope of recovery in a climacteric case for four or five years, except there are symptoms of dementia or fixed delusions. The physiological period of life not being a fixed or always a short time, therefore its morbid, nervous, and mental accompaniments are often prolonged and irregular. The period of the climacteric in the male sex occurs at a later time of 392 CLIMACTERIC INSANITY. life than in the female, and is much more irregular and indefinite. There is nothing to mark it off so clearly as the menopause. Sexual power re- mains, but the appetite for it is not in normally constituted persons keen or pervading. There is little or no self-control needed to restrain it, as in earlier years, and indeed it is commonly dormant, except when stimu- lated. The common age for the "grand climacteric" in man is from fifty-five to sixty-five, a few cases occurring before and after those ages. The popular tradition puts it at sixty-three. The procreative power of man has been demonstrated by statistics to become progressively less after fifty, and to be in reality small at the latter age. The normal mental change in man is essentially the same as in woman. The abnormal mental changes that are seen in some cases at the climacteric period in men are the same in general type, too, as in women. The spontaneity, the courage, the mental aggressiveness, the necessity to energize actively, the poetic sentiment, the keenness of feeling in all di- rections, all these are impaired. There is no drawing towards the other sex, and no subtile delight in its presence. The sleep is less sound and shorter. A cloud of vague depression rests on the man, who shuns society, falls off in fat, becomes restless and hypochondriacal, and feels strongly the tedium vitce. This may go on to suicidal longings and desires, which are usually not very intense. In fact, nothing is intense with the man. His energies, his functions, and his vitality have all been lowered. With this there is no atheroma, arcus senilis, or proper senility. The following was an aggravated case of senile insanity in the male sex : K. X., aet. 56. A quiet man, of melancholic temperament, steady and industrious in his habits, and with no known heredity to insanity. Lately he had little work and not much food, and was therefore anxious and underfed. He gradually became dull, and possessed with the fear that something dreadful was going to happen to him and his family a fear founded on realities at first, but gradually assuming a delusional character. He became taciturn and wearied of his life, ceased to take any interest in anything, and could not be roused. One morning, just before coming into the asylum, he told his wife to get up at once and conceal herself, as he had a strong desire to kill her and others. On admission he said he felt very badly, that strange and frightful ideas came into his head and preyed on his mind. One minute he was looking the picture of misery and sitting quite still, then he would lose control over himself and become restless and impulsive, and strike and bite those near him. He was thin, pale, flabby in his muscles, and his skin dark, muddy, and pigmented. He had been blistered at the back of his head before ad- mission (blisters are good treatment for some cases of insanity, but not for a half-starved, melancholic workman at the climacteric). He had a vague, indefinite dread on him, and an absolute lack of interest in any- thing in life, though his memory and general intelligence were good. His tongue was foul, his bowels costive. There were no visible signs of atheroma of the arteries. He took his food fairly well at first, and was ordered extra diet, porter, and Parrish's syrup of the phosphates. He improved considerably for the first six months in body and mind, but he never got to enjoy life or to be sociable. After that time he got worse, did not take his food well, and fell off again in flesh. Everything was CLIMACTEEIC INSANITY. 393 done to improve his appetite, and nourishment, quinine, cod-liver oil, the phosphates and hypophosphates, garden work, and amusements were all tried, but he got steadily worse. He became more solitary and silent. His blood got so abnormal that at one time purpuric spots appeared over his legs. His delusions assumed more of a hypochondriacal character before his death, which took place two and a half years after admission. He thought all his organs were diseased, and that he had no stomach. He died suddenly at last, being then a mere skeleton from exhaustion. The brain convolutions were found to be atrophied and very anaemic ; the arteries had begun to show the atheromatous degeneration ; there were some granulations on the floor of the fourth ventricle, and the lateral ven- tricles were dilated and filled with a pink serum. There was a patch of Avhite softening, about the size of a filbert, in the centre of the left hemisphere. The aorta was markedly atheromatous. This case had not had during life any of the distinctively senile mental characters, yet the pathology was undoubtedly like that of many senile cases. Of a much more common type was the following less aggravated case : K. Y., set. 57, a professional man, who had worked very hard indeed. He had a slight and distant heredity to mental disease. His professional work became a burden to him, and he lost all confidence in doing it, so that he had to give it up. He did not sleep well, became much depressed, and was very miserable, obstinate, and hypochondriacal. He had quite made up his mind that he was not to get better, and would do nothing towards his own cure. He did not lose his self-control. He simply changed his habits, avoided his friends, neglected his personal appearance, was absolutely idle, and might be said to have become morbidly ".selfish." With all this there was apparently no lack of reasoning power, or general intelligence, and this made the whole thing the more trying to his friends. When a man who cannot reason acts unreasonably allowance is made for him, but when a man acts unreasonably who can reason, the natural impulse is to blame him and hold him fully responsible. Fortunately he did not give up going out into the fresh air, and this was his ultimate salvation, for he slowly improved, and in the course of about five years he got perfectly well, and resumed his business, though he never could do as much, and was never " quite the same man," but was about as happy as the average of his fellow-men in their post-climacteric. No doubt if he had taken to his bed, or to staying in the house, as so many such cases do, he would never have recovered. In his case, as that of many others I have met with, the first decided symptoms of mental improvement were coincident with an eczematous skin eruption. I have seen gouty, syphilitic, and all sorts of skin eruptions come on in such cases during the disease, usually greatly to the patient's mental benefit. The prognosis and other points in climacteric insanity are best brought out by a statistical study of a number of cases. In the nine years (18741882) I have diagnosed as such two hundred and twenty-eight cases of the thirty-one hundred and forty-five that have been admitted into the Royal Edinburgh Asylum in that time. Of these the large pro- portion of one hundred and ninety-six were women, and only thirty-two being men. The table below shows their ages. We see that by far the majority of the female cases occurred between 394 CLIMACTERIC INSANITY. forty and fifty, and the majority of the men between fifty-five and sixty- five. As regards the symptomatological forms assumed by the cases, only thirteen of the men and fifty-six of the women, or eighteen per cent, of the whole, were acute in character. It is essentially, therefore, a subacute psychosis in its general character. Of the whole, only eighty- two were cases of mania, the remaining one hundred and forty-six being melancholic. One-half the patients were suicidal in intent at least, but few of them have made very serious or desperate attempts to take away their lives, though to this there were some exceptions. There was a high proportion, but a low intensity of suicidal impulse. Ages. Males. Females. Total. 35 to 40 17 17 40 45 .30 55 60 65 45 ... 74 74 50 ... 81 81 55 7 19 26 60 14 5 19 65 9 ... 9 70 2 ... 2 32 196 228 The results of treatment showed that one hundred and twelve cases, or fifty-three per cent, of them, recovered, the women recovering in the largest proportion. In fact, only thirty-one per cent, of the men got well, while fifty-seven per cent, of the women did so. The numbers who died, on the contrary, were greater proportionately in the men than the women, four of the former, or twelve per cent., and seventeen of the latter, or nine per cent., having died up to this time. This would seem to indicate that the disease is rarer, less curable, and more deadly in the male sex than the female ; but the numbers are perhaps too few on which to base a correct generalization. The patients who recovered had not been so long ill as I had previously imagined. Taking the time they were under treatment in the asylum (the only correct basis I have on which to estimate the duration), sixty- one of the one hundred and twenty-two who recovered, or fifty-five per cent., were discharged within three months, and eighty, or sixty-five per cent, within six months, and one hundred and eleven, or ninety-one per cent., within twelve months. There were a few patients who recovered after two years of treatment. The maniacal and the melan- cholic cases recovered in about equal proportion, but the maniacal in shorter time. The recoveries were much fewer in the women over fifty, only twenty-nine per cent, of these getting better. Up to fifty they recovered equally well. At the other ages, from fifty-five to sixty, the cases were the most curable in the men. Only three of the eleven over sixty got over their malady. 1 1 These statistics may be profitably compared with those of Dr. Merson's admirable paper on this subject, in the We-t Kiding Lunatic Asylum Medical Eeports, vol. vi. p. 85. SENILE INSANITY. 395 SENILE INSANITY. The psychology of normal old age has yet to be written from the purely physiological and brain point of view. Poets, dramatists, and novelists have had much to say of it from their standpoint. King Lear is beyond a doubt a truthful delineation of senility, partly normal and partly abnormal. By normal senility I mean the purely physiological abatement and decay in the mental function running pari passu with the lessening of energy in all the other functions of the organism at the latter end of life. No doubt, in an organism with no special hereditary weak- nesses and that had been subjected to no special strains, all the functions except the reproductive should decline gradually and all together, and death would take place, not by disease in any proper sense, but through general physiological extinction. The great function of reproduction stands in a different position from all the other functions of the organism. It arises differently, it ceases differently, and it is more affected by the sex of the individual than any other function. It is, as a matter of fact, not entirely dependent on individual organs. It may exist as a desire and an instinct without testes, or ovaries, or sexual organs. It is really an essential, all-pervading quality of the whole organism, and to some extent of every individual organ, not one of which has entirely lost the primordial fissi- parous tendency to multiply. But the physiological period of the climacteric has determined and ended it in its intensity and greatest power, though many of its adjuncts remain ; and in the male sex we have to reckon with it and its abnormal transformations to some extent even in the senile period of life. Physiological senility typically means no reproductive power, greatly lessened affective faculty, diminished power of attention and memory, diminished desire and power to energize mentally and bodily, lowered imagination and enthusiasm, lessened adaptability to change, greater slowness of mental action, slower and less vigorous speech as well as ideation, fewer blood- corpuscles red and white, lessened poAver of nutrition in all the tissues, a tendency to disease of the arteries, a lessening in bulk of the whole body, but notably of the brain, which alters structurally and chemically in its most essential elements, the cellular action and the nerve currents being slower, and there being more resistance along tfie con- ducting fibres. In the young man there is an organic craving for action, which, not being gratified, there results organic discomfort ; in the old man there is an organic craving for rest, and not to gratify that causes organic uneasi- ness. The three great dangers to normal mental senility are hereditary brain weakness, a diseased vascular system, and the after-effects of over- exertion or abnormal disturbance of brain function at former periods of life which have left the convolutions weakened. The hereditary predis- position to mental disease that has not shown itself till after sixty must, no doubt, have been" slight or well counteracted in the conditions of life, yet in many brains it never shows itself till then. Until the organ had begun physiologically to lose its structural perfection and its dynamical 396 SENILE INSANITY. force, the pathological phenomenon that we call mental disease was not developed. As we shall see from a statistical study of clinical cases, heredity to insanity was less common in the cases of senile insanity than in any other form of mental disease except general paralysis ; but there is this fallacy, that the facts about heredity were further back and more forgotten in this than in any other form. An old man's living relatives are few, and his ancestors' history far off. We may put it down as a certain law of nervous heredity, that the stronger the predisposition the sooner it manifests itself in life, and the weaker it is the later in life it shows itself. To have survived, therefore, the changes and chances, the crises and perils of life with intact mental function till after sixty, means slight neurotic heredity or great absence of exciting causes of disease. It is impossible to fix an age at which physiological senility begins, and therefore we cannot fix an age for senile insanity. Some men are older at fifty than others are at seventy. I believe that in some cases neurotic heredity assumes the special outcome of early senility that is, of early wear-out or poor organic staying power. Most congenital imbeciles and idiots grow old soon. Very many races of men grow old early, like the Kalmucs and Hottentots ; but, roughly speaking, in our race one cannot call a man old till he is sixty, though I have often met with senile mental symptoms between fifty and sixty, and, as we know, atheromatous arteries and consequent tissue degenerations are common enough before then. But in speaking of senile insanity, I shall include no one under sixty years of age. It is, of course, a well-known fact that mental disease, speaking gen- erally, is a disease of middle and advanced life rather than of youth. Of the general population under 20 a very small percentage become insane. Only 0.9 per 10,000 of the general population under that age are sent to asylums in a year in England and Wales, while 11.4 per 10,000 over 60 are so sent, or about twelve times the proportion. The best foundation for what I have to say of senile insanity will be the chief statistical and clinical facts recorded about 203 cases (71 males and 132 females) that have been classified under that heading in the nine years' admissions to the Royal Edinburgh Asylum, 1874-82. The total number of patients admitted in that time was 3145, and they were of all classes, from the sons of peers of the realm down to the lowest beggar. Of these, 304, or 9.6 per cent., were over 60 years of age. One remem- bers this better by thinking that one-tenth of them were over 60. But of these 304 cases only 203 were called by me senile insanity. The other 101 were mostly epileptics, old cases of long-existing mania or dementia, or cases of climacteric insanity that is, old age had acted as a predis- posing or exciting cause of the mental disease, and the symptoms were more or less characteristic of senility in those 203 cases only. Six and a third per cent, of the whole admissions, or one-sixteenth of them, were thus cases of senile insanity. It is, therefore, a common, but not the most common, form of insanity, as compared with the other clinical varieties of mental disease. The great predisposing cause of insanity, heredity, appeared to be, as I have said, very uncommon. Only 26 of the cases, or 13 per cent., were so affected. In estimating the frequency of heredity in mental dis- SENILE INSANITY. 397 ease, one has to add an enormous margin for ignorance and conscious or unconscious concealment of facts. In the nine years under review, 723 of the whole 3145 cases, or 23 per cent., were ascertained to be heredi- tary. The senile heredity, therefore, was little more than half the ordi- nary average heredity. The form assumed by the different cases is a question of great interest. I confess I was myself astonished at the immense variety of mental symptoms present. Till I had these 203 cases analyzed, I had not fully realized either the character or the results of treatment of the disease. Looking first at the presence or absence of mental depression or mental pain, I find that 69 of these cases, or about a third, were depressed, and classified by me as laboring under melancholia. To feel pain, mental or bodily, the brain needs to be to a certain extent sensitive and active functionally. But the peculiarity of many of the cases of senile insanity was, that the mental depression was merely outward in muscular expres- sion, not being felt in any proper subjective sense, and it was certainly not remembered. It was, in fact, automatic motor misery, and not con- scious, sensitive, mental pain. One of the cases lately under my care illustrates this very well : L. A., aet. 83 at death. His mental power had been failing for three or four years. At first there were failure of memory, irritability, exaggerated opinions of himself, morbid suspicions, sleeplessness, restlessness, and lack of self-control. These symptoms gradually got worse, until his memory was quite gone, and he did not know his age, or his wife, or his home. Yet his appetite was good, his health in some respects better than it had been before, for a gouty ten- dency had disappeared. He looked fresh and well, and his muscular strength in spurts was very great indeed. He had, a year or so after the beginning of the attack, a sort of hemiplegic attack, transient and slight ; and ever since it began, and going along with it as one of the symptoms of the disease, there was a slight indistinctness of speech, a want of motor activity and perfect coordination in the articulatory muscles, a change in the tone of the voice in the direction of feebleness, a difficulty in finding words, a tendency to stop in the middle of sentences, an omission of words, especially nouns in fact, the typical senile speech, with its mix- ture of aphasic, amnesic, and paretic symptoms. The senile speech I look on as just as characteristic as the aphasic, the general paralytic, or the hemiplegic speech, and just as illustrative of brain function. He had all the signs of advanced atheroma of his vessels. About the middle period of his disease, his memory was quite gone for recent things, and you could scarcely engage his attention for more than a few seconds on any one subject. At times, in fact, mostly, he showed a kind of happy negative contentment. If you could get the thread of his old life, he Avould tell old stories, make speeches, and look as wise as possible ; but all this time he did not know who you were, or where he was, or the day of the week, or the month, or the year, or what he had for dinner. Then suddenly, without any outward cause, a change would come over him. He would look most miserable, would moan, and groan, and weep (tearlessly), wring his hands, uttering disjointed exclamations of sorrow ; but he could not tell you what grieved him, and in a minute or two he might be quite cheerful, and he remembered nothing about it, 398 SENILE INSANITY. denying that he was at all dull or ever had been so. Or he would at times suddenly, causelessly, become intensely suicidal, trying to strangle himself, running his head against the wall, or clutching his throat with his hands. In that condition you could not rouse his attention. He was, in fact, practically unconscious, and when controlled or prevented carry- ing out his suicidal attempts, he would struggle and resist desperately and unreasoningly. At other times he would have sudden homicidal attacks. But in half an hour after all this he would be calm, chatty, and utterly oblivious of everything that had occurred. The whole thing, in fact, the pain, the suicidal and the homicidal impulses, were so many automatic acts unaccompanied by motive, reason, or remembrance, and were the mere motor signs of some organic discomfort. All his worst symptoms used to come on at night, when he would become noisy, rest- less, shouting, resisting, and quite unmanageable, alarming the household and neighborhood. The continuance of those symptoms wore out every- one connected with him. Of all forms of insanity, the senile is apt to become most aggravated at night. It might be supposed that there could scarcely be any conceivable circumstances under which a man of that age, with means enough to procure proper attendance, would have to be sent from his own home. Yet those circumstances occurred. Home treat- ment was a failure, and could not be any longer persisted in. Certainly he did better in a villa of the asylum, with plenty of fresh air and regu- lated exercise "little and often," regularity of life, lots of milk and eggs, and digestible, plain food, and good skilled attendance ; getting fat and sleeping far better. But, of course, he slowly got more enfeebled in mind ; his suicidal impulses became less intense, his noise at night less, and his resistiveness more controllable, but his motor restlessness re- mained. All his symptoms were irregularly periodic and remissional. For months he would be quiet, and then would have a few weeks of motor excitement, and night noise, and impulsiveness. What is the cause of these aggravations in senile cases and they are very common, almost universal ? I really do not know. I presume one must look on them as being partly mere action and reaction, activity and exhaustion simply. In such a case we can have no reproductive periodicity to deal with. He died of simple senile exhaustion, but with resistance to feed- ing, restlessness, and noise to some extent, up till three days of his death. It is very difficult to know how to classify such a case symptomatologi- cally. There was undoubted dementia, and there was maniacal excite- ment. There were all the outward signs of suicidal melancholia, and the symptoms of true impulsive insanity. I adopt the rule, that wherever there is marked mental pain, or the outward signs of it, the case is put down as melancholia in our books. L. A.'s case is a typical example of pure senile insanity of the melancholic type. But many of the cases of senile insanity classified symptomatologically as melancholia were entirely different from this case. Several of them were cases of simple melan- cholia that proved to be transient, its only special senile character being that it occurred in old people, was accompanied by more loss of memory than usual, and the recovery it ended in had somewhat of normal senility in it. Several of the cases were caused proximately by bodily diseases that exhausted the strength or lessened the blood-corpuscles, or by moral SENILE INSANITY. 399 causes. It is quite common in my experience, and, I believe, in that of all medical practitioners, to find certain old persons much depressed in mind by any bodily disease. Notably I have seen this happen in the course of bronchitic or heart troubles, where the blood was not aerated. In fact, given a senile brain, atherornatous arteries, and non-aerated blood, and we are pretty certain to have the mental functions of the brain affected. I am in the habit of speaking loosely of "cyanotic delirium " and " cyanotic insanity" from the non-oxygenation of the blood in bron- chitic and cardiac disease. Others of my cases of senile melancholia had fixed melancholic delusions. Intense suicidal feelings were rare, and very determined attempts still more rare, but we cannot depend on this rule in all cases. Of the sixty-seven melancholic cases, seventeen were acute in symptoms, and fifty were mild. Of the melancholic patients, thirty per cent, were discharged as tech- nically " recovered " that is, in all of them their worst mental symp- toms disappeared, they passing into normal senility. In many cases they became quite well in an absolute sense. In the melancholic patients, speaking generally, the recoveries were apt to be better than in any other class of senile cases, as in the following example : L. B., aet. 77, a man of reserved disposition, steady and temperate habits. There was no known heredity to insanity. He had never shown any disposition to depression of mind before. He had done his modest work in life well ; had brought up a healthy and well-doing family, and was an intelligent and religious man. His business was not prospering, and he became depressed and restless. He imagined he was eternally lost, that the diminution of his business was a direct judgment of God for his sins. This in religious people, and in irreligious ones, too, is a very common melancholic delusion, and the public will always have it that any kind of religious delusion or "religious insanity " is a very bad symptom in every case, and necessarily incurable. Now there is only a little truth in this. The idea has arisen, no doubt, from the fact that the cases with fixed delusions of a religious kind the prophets of the Lord, the sons of God, the possessed with a devil are usually incurable, and such cases make a very strong impression on the public mind. L. B. gradually got worse, and talked of committing suicide by throwing him- self over the North Bridge a fearfully suggestive and then low-parapeted place. After eighteen months of treatment at home, he got so ill that he was sent to the asylum. On admission he was depressed, restless, un- settled, and talkative, with religious delusions. He looked an old man, with atheromatous arteries, and there were senile cataract and marked heart disease ; but his appetite was good, and his general nutrition and strength very fair for his age. He did not sleep well at first. He was ordered Parrish's syrup of the phosphates, cod-liver oil, with milk diet, and fresh air when the weather was suitable. There was a hypochon- driacal character about his mental depression all the time. In about two months he had strengthened and improved. He became more obviously concerned about the state of his bowels than that of his soul. He was one of the melancholies a numerous array who heard "the clock strike every hour of the night." In about nine months he was almost free from the mental depression, and his memory had got better, while 400 SENILE INSANITY. he looked quite ruddy and hale. In a year he was really quite well, and was sent to his home just as cheerful and more active than the average man of seventy-eight. He came out to see us for three years after, in no respect the worse, mentally or physically, for his interlude of two and a half years of senile depression and insanity, and he died peacefully at home in his eighty-fourth year. Turning now to the cases that showed no melancholic symptoms, or, at all events, where such symptoms were not long continued or prevailing. There were 134 of these, all of whom having some sort of motor excite- ment, they were put down at first as cases of "mania." As I do not recognize "dementia" to be curable when used in a correct sense, I scarcely ever at first diagnose any recent case as such, no matter what the symptoms are at the time. To my mind, a patient is only proved to labor under dementia when he is proved by lapse of time to be incurable, and has the symptoms of mental enfeeblement as well. Many of these 134 senile cases were really cases of dementia, but I put them down as mania at first, because their enfeeblement of mind had not been proved to be incurable, and because they had more or less motor excitement. In only 19 of these was the excitement so intense as to be classified as acute mania. The mental symptoms in these 134 cases, like those of the melancholy cases, were very different in kind and degree, duration and result. Some were short sharp brain-storms preceding death, outbursts of delirious excitement accompanying the break-up of the organism. Instead of a long and gradually progressive failure of convolutional func- tion, in such cases it ended in a quick and tumultuous fashion. Instead of mere loss of power from innate trophic failure and want of blood, in such cases there is a vaso-motor paralysis and a development of irregular cellular energy, expressed outwardly by constant talking, shouting, inco- herence, loss of memory, loss of attention, sleeplessness, and, above all, by a constant motor restlessness by night and day, but especially by night. This was such a case': L. C., set. 78. He had been pretty well up to three months ago, and at that time the excitement and exertion of moving from one house into another seemed to exhaust him. He first became stupid and peculiar, and this come on suddenly, being noticed particularly .one morning. He gradually became excited, incoherent, threatening, unmanageable, and his memory was lost, but for ten days only, before being sent to the asylum, had he been very excited. The whole household and neighbors were disturbed by his noise, and his friends and doctor decided that he must be sent to an asylum. On ad- mission, he was weak muscularly, spoke with the voice and articulation of a very old man ; he was confused, and his memory was gone. He said he was forty, and could not answer almost any question correctly. His heart's action was weak, and there were moist rales heard all over his chest, but there was no acute disease, his temperature being 98.4, and his pulse 80. The left side of his face was slightly paralyzed, and his pupils unequal. There was no paralysis of arm or legs. He did not sleep, and was noisy and excited all night. There was much diffi- culty in making him take his food, too. His bronchitis was bad, and his cough very troublesome. Within forty-eight hours after admission, he got pale and weak, his breathing became labored, and he died suddenly SENILE INSANITY. 401 that day. There was no post-mortem examination. His relatives natu- rally were very sorry they sent him to the asylum, and were inclined to blame the doctor who recommended it. No doubt, if the result could have been foreseen, no one would have recommended his leaving home, but I do not think there were any definite symptoms present pointing to the result. When consulted about cases of senile insanity, I always have before my mind the question, "Are those mental symptoms not the mere forerunner and accompaniment of a general break-up ?" And to answer that question it is desirable to go into the condition of the brain, the heart, the lungs, the kidneys, and the general strength very carefully. I am always suspicious of sudden oncomings of mania in old people being of this character. The following case was typical in its inception, symptoms, incidents, duration, and pathology : L. D., set. 78. Had been hard-working, and as drunken as his limited means would allow. Senile insanity is often the penalty for an excessive use of alcohol in earlier life. About nine months ago he got a fall down stairs, and has not been so strong or well since. About six months ago, his memory began to fail, then he became stupid and confused, then suspicious, then restless, then unmanageable, then violent to his wife, and was then sent to the asylum as a pauper patient. On admission, he was confused, slightly excited, very restless, his memory gone, his general condition Aveak, his senses blunted, his speech senile, his pupils irregular in outline, his tongue tremulous, his pulse 90, weak and intermittent, his temperature 98.2, his lungs and other organs healthy, and his appetite good. He was well fed and nursed in our hospital ward, but, though he gained in flesh, he did not improve. He was restless, especially at night, became gradually dirty in his habits, moved about in a purposeless way all the time. The motor restlessness of a senile case is an extraordinary vital phenomenon. He never sits down, seldom sleeps, he shouts, and walks about his room all night, and yet never tires. I found that this symptom existed in sixty per cent, of all the cases. Whence the source of all this most unnatural muscular energy ? It exhausts his small stock of real strength, though he does not feel it. It is the antipodes of the quietude and disinclination for exertion of the normal old man. About three months after admission, as he was aimlessly carrying a chair in the day-room, he slipped, falling down, and breaking his right femur at the neck inside the capsule, an accident always liable to happen to a senile patient. He got on pretty well, being left in bed and nursed and cared for as well as was possible. In about two months the restless- ness came on again, and in trying to rise he hurt his leg again. In about a month he died of exhaustion, having been ill for ten months, there being much difficulty in preventing the formation of bed-sores before death. The difficulty of managing such cases satisfactorily in an asylum or out of it is extreme. They are very restless, always meddling with something or somebody, very obstinate, entirely forgetful and purposeless. They are constantly making their water on the floor, in a corner of the room, or in another patient's hat. They need bathing often. Their bowels are either too costive or too loose. They are liable to retention of urine from enlarged prostates and bladder paralysis. They either eat too 26 402 SENILE INSANITY. much or will not eat at all. A slight fall breaks their bones. To lie near other maniacal or irritable patients is out of the question, for they are sure to get hurt. For them one requires to use the best attendants, the best single rooms at night, and the best parts of a fully-equipped hospital ward; and all this needs to be done by nurse and doctor under the depressing feeling that it is of no use in the long run towards the cure of the patient. On a post-mortem examination of L. D's. case the pia mater and arachnoid were found thick and opaque, but stripping freely off the con- volutions, which were over the vertex of the brain atrophied and covered with an opaque compensatory fluid. On section the gray substance of the convolutions was irregularly thinned and soft in texture, the peri- vascular canals being enormously enlarged. In the extra-ventricular nucleus of the left corpus striatum there was a recent hemorrhage the size of a pea, and in the right optic thalamus one of the same size of older date. There was a small softening from embolism or thrombosis in another part of the thalamus. The lining membranes of all the ventri- cles were granular, and the lateral ventricles were enlarged from intersti- tial brain atrophy. All the brain arteries were atheromatous in patches, causing diminution of their lumen at these points. There was dilatation of both ventricles ; aorta was very atheromatous, lungs were oedematous, liver slightly nutmeggy, right kidney disorganized and the seat of an extravasation of blood. On microscopic examination the large cells in the inner layers of the convolutions were found in the degenerated atrophied state, with their processes gone, as represented in Dr. Major's plate (Plate VIII. Fig. 4). 1 There was much debris round the vessels in the perivascular canals. In some few of the cases the pathological appearances are indicative of a much more intensely disturbed state of the convolutions during life. For instance, in a case I examined, L. E., aet. 76, who had been ill for fifteen months, the last three of which were spent in the asylum, and who had, in addition to the symptoms of the last case, great violence at times, wanting to get out of his house, which he maintained was not his own, an epileptiform attack, a very indistinct, thick, scarcely intelligible articulation, all his symptoms remissional, more emotionalism, and a temperature of from 99 to 100, we found after death great adherence of the dura mater to the skull-cap, and a very dark- colored false membrane, varying from a quarter of an inch in thickness, covering the whole of the vertex, and descending down and covering the base in a thin layer. In this membrane there were several pure blood- coagula from the size of a pea up to that of a small walnut. The pia mater was not adherent (though in two or three senile cases I have found it to be so), the ventricles were granulated, and there was much general atrophy. There was hypertrophy of the muscular substance of the heart and aortic incompetence. The following is a case of transient senile mania ending in recovery : L. F., set. 63, a man of a cheerful disposition and somewhat intemperate habits. By the way, liquor undoubtedly affects an old man far more than a young one in the direction of producing insanity as well as less marked 1 West Hiding Medical Keports, vol. v. p. 161. SENILE INSANITY. 403 neuroses. It tends more towards tissue degeneration at advanced ages, and the nerve tissue suffers most in neurotic subjects. There was some insanity in the family, but he came of an otherwise sound, long-lived stock. Three months ago he had an old ulcerated leg healed up. Had a perineal abscess a fortnight ago, which was opened, and since then has been affected in mind. The attack is recent, and came on suddenly. He began to take fancies that he was rich, got excited, and had a great crav- ing for drink, which he indulged, and got much worse after it. On admission he was greatly exalted, saying he was possessed of all knowledge, power, and wealth. He was excited, shouting and crying, said he was the "Messiah God," that he had millions of money. He did not sleep, and his appetite was poor. He was dirty in his habits, and constantly restless. He was fed well, and got tonics, chiefly iron and quinine. Within a month was quiet and almost rational and free from delusions. In about three weeks more he began to suffer from headaches, and soon became melancholic and morbidly anxious about his health. After having begun to sleep well, he again lost the power of sleeping in this melan- cholic stage. In about another month he gradually got out of the depression, and passed into a quietly contented, rational sane senility. He went home, and ended his days in peace after some years. He entered on the attack a middle-aged-looking man ; he came out of it visibly an old man in body and mind, but in no respect a dotard or unfit to manage his affairs in a quiet way. This was a case of senility ushered in by a brain-storm. Mentally he at first resembled a typical general paralytic. Looking at senile insanity broadly, there is no doubt that its pure type is to be found in the restless, sleepless dotard, without memory, without true affectiveness (at the beginning of the disease there are often affective hypersesthesia and uncontrollable emotionalism), without crisp, articulate speech- second childhood in an unmanageable form, in fact. That is the true senile dementia, out of which there can be no issue but death. Of this class of case there were in a typical form sixty-two cases of the two hundred and three, or thirty per cent. That statistical result was a surprise to me. I had expected more of that type. Some of the others seemed to be of that character at one period of the attack, but they came back to something like normal mild senility. As might have been expected on physiological grounds, the typical cases of senile dementia were found in greatest numbers at the more advanced ages, but from sixty up to seventy-five there was no regular increase in their number. Under seventy-five there were only eighteen per cent, of typical dotards ; over seventy-five there were over fifty per cent. Some of the cases were quite strong in body, and, beyond some arterial degeneration, showed no signs of bodily disease, and their mental condi- tion was a cheerful forgetful enfeeblement. I have one such man of seventy, as good a garden worker as we have, who sleeps well and eats well, but cannot tell you the day of the week, calls me an old friend, and has no idea where he is. Another marked type is that of pure senile elevation, with delusions of great possessions and power, as in L. F's. case. Such delusions, existing along with mild maniacal exaltation and the senile articulation, are very like cases of general paralysis. They are 404 SENILE INSANITY. constantly diagnosed as such, in my experience. But general paralysis scarcely ever appears after sixty, and never after sixty-five. A close study of the speech, too, Avill usually determine the difference. There is not the true general paralytic fibrillar trembling, or the spasmodic convulsions of the smaller facial and labial muscles. Quite a number of cases were of that type in the early period of their disease. One such case of sixty- five, A. H., had millions of money ; the asylum belonged to him ; he would give you a thousand pounds for the asking ; he was happy as a king, and he was constantly restless, pulling off his buttons and taking off his clothes. His speech was thick, hesitating, and wanting in crispness of tone. He gradually became hemiplegic, and died in about two years, a dotard. A large embolic softening was found in his corpus striatum, as well as several smaller softenings in the convolutions of the motor area of the cortex. Many senile cases have hallucinations of hearing. I have now two old women who hold regular conversations with people in the ceiling and in the next room. Some of the men develop a morbid eroticism and a physiological immorality. Many a marriage I have known to be made by commencing senile dements. I had one patient of eighty, L. G., whose conduct towards his female nurses was so bad that few respectable women could be got to look after him, and yet he was of the melancholic type, "just going to die" every day. Masturbation is not unknown in senile insanity. The hypochondriacal mental symptoms that are certainly one of the most characteristic features of the cases of climacteric insanity are sometimes' seen in senile cases. In most cases there are morbid sus- picions at the beginning. I had an old lady patient who dismissed her old faithful servant two or three times a week for stealing her clothes. I saw one lately who believes that her neighbors come into her house and plot to rob her of her money. The characteristic of the senile suspicions is that they refer to things that are possible to happen, to stealing of clothes or money, to faithlessness on the part of near relations, etc., and do not refer to the impossible things that cases of real monomania of suspicion believe, to electric and mesmeric agencies, or to elaborate social plots. The senile cases are constantly changing in their suspicions and fancies, too ; one day it is one thing, another day another. In a few of the cases food is refused a very troublesome and a very grave symptom. To feed an old man or woman by the nose- or stomach- tube does not seem, somehow, to be followed by such good results as the forcible feeding of younger patients. The mucous membrane of the mouth and fauces is apt to get dry, and diarrhoea to set in. In two or three cases hoematoma auris developed during the acutely maniacal stage, this no doubt indicating marked vascular disease and trophic disturbance. The ages of the cases are best seen by a glance at the table below. 1 1 Age. Total Nos. Recovered. 60 to 65 62 24 70 63 21 70 7. -> SO 85 75 40 15 80 30 9 85 3 1 90 5 2 203 72 SENILE INSANITY. 405 Taking the whole number of cases (203), over 60 per cent, of them were between 60 and 70, 35 per cent, were between 70 and 80, and about 4 per cent, over 80. That is not far from the proportion at those ages in the general population over 60. The chief difference is that the propor- tion of insane persons between 70 and 80 is greater, while the proportion of the sane over 80 is double that of the insane. One of the most interesting and important of the results I obtained from an analysis of those 203 senile cases was a clearer idea than I had before of the course of such cases, their duration, and the results of treat- ment. The general result was that seventy-two of the cases, that is, 35 per cent, of them, were discharged from the asylum recovered ; and sixty- nine cases, that is, 33 per cent., have died ; while thirty-three cases were discharged more or less improved or not at all improved, leaving twenty- nine cases under treatment. The striking fact is the number of recoveries. I must explain that the "recovery" from any form of senile insanity need not necessarily be, and is not, as a matter of fact, an absolute restoration to vigor of mind. Some such complete recoveries there were, men who went out and earned their own livelihood, women who went out and governed their households. But such cases were usually the short attacks of exaltation or depression that I have referred to. They mostly occurred between the ages of 60 and 75, though they were not absolutely unknown after. At least one-half of the recoveries, perhaps rather more, were returns to or gradual passings into comfortable, manageable, normal senility. That is all that can be expected in a case with the typical characters of senile insanity. It is all I ever lead the relations to expect will occur. But it is a most happy change from senile mania. To have an aged father or mother pass out of such a condition, and become fit to go home and be lovingly cared for till death takes place, is an occurrence for which most persons of proper feeling will be profoundly grateful. When such a return to normal senility occurs, there is usually little tendency for the excitement to return under proper care and feeding. The recovery rate in each quinquenniad from 60 to 75 was about the same, and the rate in that whole period of fifteen years was 36 per cent., or 60 cases out of 165. The numbers in each of the next quinquenniads were too small to give results worth generalizing on, but the total number of recoveries in the thirty-eight cases over the age of 75 was twelve, or at the rate of 32 per cent. This last was one of the results that surprised me, I confess. The recoveries took place in about the usual time that recoveries from other forms of insanity take place. About one-half (47 per cent.) of them were discharged recovered within three months of residence, and over three-fourths (79 per cent.) of them within six months. In fact, rather a larger number recovered within six months than the average recoveries in an asylum. Sixty-nine of the 203 cases have died up to this time. There is much risk of them dying within the first month ; this, of course, meaning that in a considerable number of cases the mental disease is of the nature of an ante-mortem delirium, like L. C.'s case I have related. Seven per cent, of the cases died within the first month, making about 20 per cent, of the whole of the deaths. Far more died in the first than in any sub- 406 SENILE INSANITY. sequent month. More than half the deaths occurred within the first six months of residence, that being a considerably earlier period of death than occurs in most other forms of insanity. PATHOLOGY OF SENILE INSANITY. The pathology of the disease is interesting because it has some approach to definiteness. It is, next to general paralysis, the form of mental disease in which the most distinct pathological appearances are found in the brain. Out of the ninety-two deaths we were allowed to have post-mortem examinations in fifty-two cases. I often find it unusually difficult to obtain permission for j)ost- mortem examinations in senile cases. An exhaustive analysis of the pathological appearances found in these fifty-two cases would be far too "tedious to attempt. Many of the cases would need a special description to do them justice. All I shall attempt is a summary of the chief ap- pearances. The most common of all the lesions found in the brain itself was that form of combined cerebro-vascular disease, commonly called softening of the brain. This occurred in a marked form in twenty-two cases, or forty-two per cent, of the whole. I need hardly say that I use the term in the proper sense of a ramoUissement, a localized necrosis, partial or entire, of a portion of brain tissue, resulting in most cases from a deprivation of blood through embolism or thrombosis of the arterial branches supplying it. In every case of softening there was marked vascular disease, and in many cases the obstructed vessel that had formerly supplied the starved portion of brain could be demonstrated. Commonly the form of vascular disease was atheroma in an advanced form, sometimes aneurisms, large and small, sometimes inflammatory general thickening of the coats of the vessels. The softenings were com- monly localized and seldom very extensive, in this differing markedly from the softening found in the brains of younger insane persons. They were found everywhere, but the most common sites were the great basal ganglia, notably the corpus striatum, and the convolutions of the vertex and lateral portions of the anterior and middle lobes. The appearances of the softenings were very different in different cases, according to their duration and the sudden or gradual onset of the lesion. When a twig of a cerebral artery is suddenly obstructed by an embolic plug, most of the tissue supplied by it dies at once, a sort of inflammatory process (the "red softening" of the older pathologists) taking place for a few days first. Then it liquefies from the centre outwards, appearing as the typical "white softening," the process usually tending to spread into the sound tissue, but sometimes, if the dead portion is very small, the debris gets partly absorbed and the tissue round it sacculates, or, in still rarer instances, shrinks together, forming a condensed cicatrix-looking spot. But no doubt the common thing is slow progression of the softening, in accordance with that fatal law of progressive nerve-tissue degeneration first described by Waller in the peripheral nerves, and which has since been found to exist in so many nervous diseases. In senile cases the softening process is commonly gradual through the slow starvation of an area of brain tissue from a gradual atheromatous diminution of the lumen of its supplying vessel. I did not at one time believe in a non-syphilitic senile arteritis affecting all the coats of the vessels. Now I do, for I have seen it. And I know of no test to distinguish such arterial disease from SENILE INSANITY. 407 the more common syphilitic arteritis. In that case there is no preliminary red softening, but a slow absorption of the nervine tissue, a corresponding compensatory development of the less vitalized neuroglia and packing and retaining tissues generally, giving the appearance at first of a spongy gray area, and going on to its complete atrophy and disappearance. The ap- pearance caused by the sudden and the gradual starvation process differs much in the convolutions and the white substance. The former having about five times the blood-supply of the latter, it is far more apt to be filled with hemorrhagic debris in the sudden cases, and to have a gray, dirty, gelatinous look in the gradual cases. The convolutions or parts of convolutions affected look wasted, the pia mater comes off readily, and to the touch their resistance is very soft. It is difficult even to harden them in spirit. The chief blood-supply of the convolutions being derived from small arterial twigs from the pia mater, each twig not anastomosing much with the others, but nourishing a small convolutional area of its own, if one of these, is obstructed its area dies and softens, slowly or quickly, according to the kind of obstruction. But, as Duret and Heubner show, the convolutions have a second blood-supply from within. We do not find the complete necrosis of tissue in the gray that is found in the white substance. The former always retains some vitality, and seldom becomes a liquid pulp, or altogether disappears, like the white substance, from this cause. The next notable appearance observed was marked atrophy of the whole brain, or of considerable portions of its convolutional surface. This existed, alone or in conjunction with other lesions, in so marked a degree as to be put down as one of the direct causes of death in twelve cases, and in a lesser degree in most of the others. No doubt this atrophy is partly the same process as softening, only the starvation process is slower still, and is partly owing, not to a diminished blood-pabulum merely, but to an innate lack of trophic energy in the neurine elements. It manifests itself in brain sections by much enlarged perivascular canals and dilated ventricles. The curious way in which the cerebral envelopes and packing elements seem to make an effort to expand and compensate in bulk for the shrinking brain is, I suppose, partly connected with the physical conditions of the closed box within the cranium, inaccessible to the atmospheric pressure except through the bloodvessel openings and the foramen magnum ; and partly owing, no doubt, to the congestions of the whole of the tissues supplied by the carotid arteries and their branches that accompany the paroxysms of maniacal excitement. From whatever cause, when the brain is most atrophied we are most apt to have thicken- ings of the skull-cap, often taking the form of successive layerings of bone over the inner table where it covers the vertex, and especially over the anterior lobes, where the atrophy is usually most marked. The dura mater is commonly thickened, and usually adheres pretty strongly to the skull-cap. The arachnoid is thickened, the pia mater thick and fibrous, and the cerebro-spinal fluid superabundant, milky, and full of microscopic debris. There were recent apoplexies of such a size as to be seen by the naked eye in only five cases. Microscopic apoplexies within the pia mater, in the tissues and round the softenings, and in the perivascular canals, are 408 SENILE INSANITY. much more frequent. In fact, there are few cases of senile maniacal excitement in which such apoplexies cannot be found in these positions. But among all those cases of softening it seems marvellous that there were not more cases of apoplexy. Given vessels with weak, diseased, and inelastic coats, given atrophy and softening of the brain, the place of the solid tissue being taken by mere liquids and spots of softening, and add to these maniacal attacks implying intense vascular congestion, one would think that large apoplexies must occur in every case from the want of support to the diseased vessels. Yet we have seen this was seldom the case. The existence of small apoplexies probably explains the occurrence of transient attacks of hemiplegia, as in a very interesting senile case in this asylum reported by Dr. J. J. Brown, 1 in which the whole of the pia mater was full of miliary aneurisms, and most of the convolutions filled with pin-point apoplexies. Such cases, as well as the cases with limited softenings, bring senile insanity into close relationship pathologically with paralytic insanity, with which it has many common features. They are the two clinical forms of insanity most allied. Senile insanity often be- comes paralytic insanity. Paralytic insanity always has many of the mental symptoms of senile insanity. There was distinct meningitis in three cases, one of which was the case of L. E., with " pachy meningitis hsemorrhagica externa," referred to on page 402. Of the other organs of the body, the heart was found most frequently affected, there being marked cardiac disease in ten cases. The lungs came next, with bronchitis and broncho-pneumonia in nine cases ; and next the kidneys in two cases. In many of the patients several of the above morbid conditions were combined. With regard to the microscopic appearances in senile brains, I must refer to the careful and correct descriptions and drawings of Dr. Major. 2 We have all been able to confirm those observations, and perhaps to see some special points in addition, but have not been able to add much to them. The various stages in the degeneration of the large cells, the atrophy of the smaller cells and' nuclei, the enlargement of the vascular canals, and the debris of granules and hsematin crystals, are all well described by Dr. Major. I have met with such general atrophy, as is represented in Plate VIII. Fig. 3, in several cases in which the nerve-cells and fibres were gradually disappearing, leaving only an irregular loose reticulation of cell-walls, neuroglia, and atrophied vessels. The weak point in the pathology of senile insanity is that we have no means of comparing those lesions and changes I have described with the appearances of the brains of old persons who were not insane. Beyond a doubt, some of them, both naked-eye and microscopic, are present in persons whose mental condition never got beyond normal senility ; but there is less doubt that in the brains of fifty -two persons from the average population over sixty, there would not have been found so many soften- ings and atrophies, etc. What we have to ask ourselves, in order to form anything like a proper conception of these cases of senile insanity, is, what was the relationship between the purely dynamical phenomena of 1 Journal of Mental Science, July, 1874. 2 West Hiding Keports, vol. ix. p. 223 ; and Ibid., vol. v. p. 161. SENILE INSANITY. 409 morbid mental exaltation or depression, loss of memory, and constant purposeless motor excitement, during life, and the atrophied convolutions, the degenerated cells, the diseased vascular system, and the starved areas of brain found after death ? Did these pathological changes, when they advanced to a certain point, simply allow old hereditary convolutional weaknesses to come out that had been so slight that by nothing but slow death of brain tissue could they have become actualities instead of mere potentialities ? Or had the advancing brain degeneration simply weak- ened and destroyed all the higher inhibitory faculties and "centres" in the brain? Is the constant motor restlessness referable to the progress of the manifest changes in the larger "motor" cells of the convolutions? Is the loss of memory a mere paralysis of the power of attention and mental concentration on sense impressions a result of the loss of inhibi- tory power, in fact ? Or is it, in addition, an absolute paralysis of recep- tive capacity on the part of the cells in the convolutions, the impressions from the senses being "writ in water"? Or do the impressions not reach the convolutions through degeneration of the white conducting fibres ? As to the memory of old events, which is the last to go, is that just the result of destruction and atrophy of the cells as organized activ- ities ? What light does the whole known pathology throw on the constant connection of the mental and motor symptoms ? It seems to me that that connection in senile insanity is another proof of the motor functions of some of the brain convolutions. How can senile insanity best be treated and managed ? I can only lay down the principles that I have found useful, and can scarcely enter into the details of individual cases or requirements. The thing of first importance is undoubtedly to get a good nurse a responsible, skilled, patient, experienced person. . Women make by far the best nurses for old people of either sex, but for male patients they are sometimes not physically, strong enough. After a good nurse (and a daughter or rela- tive will sometimes make the best of all) comes the routine of management, diet, exercise, and regimen. Excitement, and new things or ways, or places or persons, should be avoided. Old people take best with what they have been accustomed to. Warmth by day and night is most important, combined with airiness of the apartments. The clothing should be warm by night as well as by day. Cold aggravates excitement and causes dirty habits. The night management is the most important and the most troublesome. It is better not to attempt to keep the patients in bed all the time if they will not stay there quietly. Struggling with them causes irritation and resistance. A suite of airy, not over- furnished apartments down stairs are the best. As to exercise in the fresh air, it is most important. It makes all the difference between being able to manage a case at home at all or to manage it well in an asylum. It should not be given up to the point of exhaustion, like exercise in young acutely maniacal cases. The walks should be short and often ; and, when the weather admits, sitting in the open air should be practised. Senile patients have a provoking habit of sleeping during the day and waking at night. Better sleep by day than not at all. The diet is also most important. I find the first food of man to be the best at the oppo- site end of life. There is nothing like milk, given warm and in small 410 SENILE INSANITY. quantities at a time, and often. Fatten your patient and you will improve him in mind. Too much flesh and beef-tea are often too stimulating and indigestible ; cod-liver oil often works wonders, and so does maltine. Fresh vegetables, or their juice in soups, should always be given. All the solid food should be minced or pounded for a large number of the cases. Sometimes it is necessary to fit up a special room in a private house for night use, without furniture, warmed, and that can be cleansed daily. Night-feeding as well as day-feeding is often needed. Often a big stomachful of hot porridge or bread and milk will give a night's sleep far better than a hypnotic medicine. The purely medical treatment is, in senile insanity, the least important, but we can do something in that way. My experience of opium is unfavorable as a sedative. It diminishes the appetite, and often kills the patient. But by means of mild doses of the bromides, with or without small doses of cannabis Indica, used occasionally as required, we can tide over bad nights comfortably. Tonics are useful, and iron and the phos- phates often work wonders. Alcoholic stimulants are often useful, but not so often as is commonly supposed. The bowels should be regulated by the simplest laxatives, some treacle or syrup given with the evening meal of porridge being often all that is needed. The great aim, in most patients, is to get into comfortable normal senility as soon and quietly as possible. In some the restlessness and noise are so pathological that nothing seems to have any effect in con- trolling or abating them. The patient and his brain simply wear them- selves out, and everyone about him is thankful when all is over without accident. Few questions are so difficult to determine as the one of send- ing a very old person to an asylum or not. The feelings of everyone go against it if there are a good home, dutiful relatives, and sufficient means. The best way is to try all other means first. In good asylums we give the poor suffering from senile insanity a sort of treatment that the richest often cannot get at home for any price, and in many instances with remarkable success. If, therefore, there are poverty and no conveni- ences for treatment, one cannot hesitate about the course to adopt. I am well aware of the imperfect view of the whole senile condition, bodily and mental, that a physician to an asylum is apt to get from seeing the very worst cases only. His picture is filled in with very black shadows. To keep himself right, he must take all the opportunities he has of seeing and studying senility outside of an asylum, which I habitually do, trying to look at it with a medico-psychological and patho- logical eye. I never see an old man who fails to interest me from that point of view. I wish physicians in general practice who have to meet the smaller emergencies of senility would put their observations before the world more than they do. I find the management of most old cases is regarded without much interest. And yet what a field of psychological study, to be able to watch the waning minds of strong men and subtile women ? LECTURE XVIII. EARER AND LESS IMPORTANT CLINICAL VARIETIES OF MENTAL DISTURBANCE. 1. ANAEMIC INSANITY. 2. DIABETIC INSANITY. 3. INSANITY FROM HEIGHT'S DISEASE. 4. INSANITY OF OXALURIA AND PHOSPHATURIA. 5. THE INSANITY OF CYANOSIS FROM BRONCHITIS, CARDIAC DISEASE, AND ASTHMA. 6. METASTATIC INSANITY. 7. POST-FEBRILE IN- SANITY. 8. INSANITY FROM DEPRIVATION OF THE SENSES. 9. THE INSANITY OF MYXGEDEMA. 10. THE INSANITY OF EXOPHTHALMIC GOITRE. 11. THE DELIRIUM OF YOUNG CHILDREN. 12. INSANITY OF LEAD-POISONING. 13. POST-CONNUBIAL INSANITY. 14. THE PSEUDO-INSANITY OF SOMNAMBULISM. IN addition to the more common clinical varieties of mental disease, there are a great number of others rarer, but of much interest and in- structiveness. Most of them are etiological varieties, but there are some forms in which the mental affection must be considered an essential part of the disease, as in rnyxoedema. I cannot enter fully into any of these forms, but I shall glance at some of them that have come under my own observation. 1. ANAEMIC INSANITY. There are a few cases of mental disease due to anaemia of the brain from starvation, chlorosis, or prolonged indiges- tion, or some other causes of anaemia. We had in the Royal Asylum fifteen of those out of the 3145 in the nine years 1874-82. Two-thirds of these fifteen were cases of melancholia, and the rest acute mania. Eighty per cent, of them recovered. This was one of those who did not: L. H., aet. 29, of a quiet and reserved disposition, and temperate habits. No neurotic heredity known. He had had no work and little food for some time before coming into the asylum, and had become weak, anaemic, and run down. He then got restless, sleepless, and unsettled, and next melancholic, attempting to go over a window. Then he became acutely maniacal. He was utterly exhausted in strength, though acutely mani- acal when he came into the asylum. The maniacal condition alternated with depression, fearfulness, fits of weeping, and partial consciousness, saying he " did not mean to do any harm." He was fed up, but he became demented and incurable very soon. Most of the cases were mild melancholia, some of them having an element of stupor, and those nearly all recovered within three months under good feeding, fresh air, and quinine and iron. 2. DIABETIC INSANITY. I have met with two cases in which melan- cholia was associated with diabetes mellitus. Both were cases of melan- 412 DIABETIC INSANITY. cholia, looked at from a symptomatological point of view. It is much the same to the practitioner of medicine how a case is classified, so long as the classification sheds new clinical light on its nature and causation. The mental condition of diabetic patients has attracted the attention of clinicists, but not so much as it deserves. We, whose practice lies chiefly in mental diseases, are often accused of seeing nothing but the mental symptoms of our cases ; but we have good reason to complain of the way in which the mental symptoms of ordinary diseases are overlooked or neglected by general physicians. The psychology of most bodily diseases has yet to be written, and one has a faint hope that the clinical study of mental diseases by students of medicine may so familiarize their minds with mental symptoms that they will be more on the alert to look for them in their ordinary practice than they would otherwise have been. When they are looked for by those who know how to observe and name them, they will be found. The whole history of medicine is one long tale of finding things when they were looked for. The first case was that of L. K., set. 59, a lady who has held an offi- cial position, working hard for many years. Never insane before, and no heredity to the neuroses. Her disease showed itself by mental depression, irritability, incapacity for work, a lack of interest in anything, and an indecision of character quite foreign to her, all these symptoms following a carbuncle on the occiput. I was consulted about her, and discovered she had diabetes mellitus, which had existed probably for a year before the mental symptoms came on. She had no appetite, could not be got to take enough food, and what she did take seemed to do her no good. She had the usual bodily symptoms of diabetes thirst, frequent mictu- rition, sugar in urine, thinness, and dry skin. On account of the diffi- culty of getting her to take enough food, to dress herself, to go out to walk, as well as her noise and restlessness at night, she was sent to the Royal Asylum about three months after the depression began. The usual treatment was adopted for the diabetes, but with no avail. Her mental energy got enfeebled, until she was entirely languid, with no volitional power. She had the delusion that she was ruined, and could not pay her debts. The only thing she did was to keep up a continual wail by day and night. The temperature was 98 in the morning and 98.4 in the evening. She became steadily weaker, and was giddy when she stood up, and towards the end became sleepy all the time. Her urine was never very copious, and its specific gravity was always about 1030. She had a small ulcerated spot on her ankle, which could not be healed, and increased slowly in size. She died rather suddenly six weeks after ad- mission. On post-mortem examination, we found the scalp and skull-cap of a yellowish hue. The inner table of the skull-cap was irregularly thick- ened by bony masses ; the dura mater was leathery ; the pia mater was thickened, and could be removed from the convolutions with abnormal ease. The convolutions and brain generally were much atrophied, com- pensatory fluid taking its place. The convolutions stood out thin, small, loosely packed, and wedge-shaped. The fornix and corpus callosum were pale and soft. The lining membranes of the ventricles were roughened, with a trace of granulations. Sections of the brain showed an irregular DIABETIC INSANITY. 413 mottling of a pink hue, and pallor of the gray substance of the convolu- tions. The whole of the cerebral substance exhibited a loss of consist- ence, and in the left corpus striaturn there was a small localized softening, the size of a split pea. The encephalon only weighed thirty-eight ounces. Dr. Campbell Clark made some sections of the medulla for me, and they all show (1) great looseness of texture, (2) localized atrophies, (8) abnormally enlarged perivascular canals, (4) degenerated and partially atrophied cells, very many of which have undergone fuscous degenera- tion, their processes having largely disappeared, like the cells in senile dementia (Plate VIII. Fig. 4). On the whole, therefore, the pathology of diabetic insanity, so far as that case throws light on it, seems to be an innutrition and general atrophy of the brain, especially affecting its convolutions. The following was another case: L. J., get. 57. Classical education ; no profession. Temperament melancholic. Disposition gloomy, variable, and excitable, implying the nervous diathesis. Habits steady, industrious, especially fond of figures. First attack. Paternal uncle insane. Causa- tion, work and worry. One particular piece of business was the exciting cause of his first mental depression, and of the fancies that he was ruined. He became restless and sleepless, and could talk of nothing but this. He got worse, and tried to starve himself, fancying that he could not pay for his food, and had therefore no right to eat it. Talked of, but did not attempt, suicide. When I saw him, eighteen months after the beginning of his illness, he was much depressed, somewhat stupid, very obstinate and resistive, and looked as if absorbed in his own morbid ideas. Gets a little irritable and subacutely excited when pressed to speak or to take food. Attention much impaired ; memory seems good as to distant events. He has the delusions that he is ruined, that he has no money, that he should eat nothing because it cannot be paid for. His countenance is haggard, depressed, and vacant ; skin cold and clammy ; muscularity flabby ; fatness is deficient ; pupils equal and contractile ; motor, sensory, and reflex functions normal; lungs and heart normal, but circulation weak; tongue furred; bowels costive; no appetite; pulse 108, weak; temperature 99.8. Unfortunately the urine was not examined at first. He ate only on great pressure, and he got no fatter. His skin became dry and harsh feeling. Mentally he remained doggedly and unreasonably obstinate as to dressing, undressing, going out, and especially as to taking his food. He read a little, and would sit by the hour making long calcu- lations, showing how, at the rate he was eating, all the food in the country would soon come to an end. Sometimes he would say he was being starved. He had no hallucinations. He had one or two small abscesses, which became ulcers, on his toes that would not heal. He was occasionally dirty. He was treated with quinine, iron, the phosphates, phosphorus pills, cod-liver oil and the hypophosphites, maltine, milk, cream, strychnine, vegetable bitters, and the mineral acids in succession or combination. He was sent for change of air to the asylum sea-side house in the summer. Sometimes temporary improvement took place, but he fell off and got thinner on the whole. He certainly could not have passed as much water as an ordinary diabetic or it would have been observed, but it was not till 414 INSANITY OF BBIGHT'S DISEASE near the end of his life, two and a half years after the beginning of his illness, that his urine was examined, at Dr. Begbie's request, and found to be loaded with sugar. He frequently saw him with me in consulta- tion, but diabetes had never been suspected till towards the end of his life. He died suddenly of exhaustion, two years and eight months from the time of his attack. No post-mortem examination in this case was allowed. These two cases of diabetes have many mental symptoms in common, though they had some differences. They were both melancholic. They both imagined they had no money, and were ruined, and could not pay their debts. They both had a disinclination to take food. They were both wanting in affection for their children. They both were thin and weak. They both had a tendency to sores on extremities, with small healing power. But the one was more resistive and dogged ; the other more passive, inattentive, and utterly uninterested in anything in the world. Death in both cases occurred rather suddenly. 3. INSANITY OF BRIGHT'S DISEASE. This is a variety of mental derangement, half delirium and half mania, which results from ursemic poisoning. I have met with several cases of this disease. Dr. Wilkes 1 has published several cases of this kind, and Dr. Grainger Stewart says he has also seen similar cases. It usually occurs in chronic cases of Bright's disease, with contracted kidneys, where there have been enlarge- ment of the heart and a tendency to dropsy for some time, and where the central nervous system has been long subjected to the influence of imper- fectly purified blood. The symptoms present are mania of a delirious kind, with extreme restlessness, delusions as to persons round the patient, an absolute want of fear of jumping through windows, or other actions that would kill or injure. The symptoms are characterized by remissions, during which the patient is quiet, rather composed in mind, and rational, but very prostrate in body. One of my cases was L. L., a man of fifty, with a family history of insanity, who had once been much depressed in mind (but was not sent to an asylum) after a fever. He seems to have had heart disease for many years, and to have had Bright's disease for at least two or three years previous to his admission into the asylum. He had dropsy of his legs for some weeks before the mental symptoms began. He was at first morose and irritable to a morbid degree, and steadily got worse in mind, his symptoms changing to exaltation and excitement, fancying he could do wonders, had absurd schemes for making money, and threatened to murder everyone near him. On admission he was in a state of mental exaltation and excitement, gesticulating, saying he had been married and had no children (which were delusions), and his memory quite gone. His speech was thick and indistinct, his tongue coated, his pupils dilated, and slowly sensitive to light, the reflex action of the cord dulled, and the temperature below normal ; legs oedematous ; his lungs were dull at bases; his heart hypertrophied, with a loud murmur with first and second sounds; urine contained much albumen, and a few tube- casts, sp. gr. 1020. This man alternated between this state of mind and that of a drowsy, stupid, but fairly rational condition, till two days 1 Journal of Mental Science, July, 1874. INSANITY OF OXALURIA AND PHOSPH ATU RI A . 415 before his death, when he got semi-comatose, with periods of delirium. He only lived five weeks after admission, or about two months from the appearance of his mental symptoms. This is a typical case of the disease. No doubt the mental portions of his brain were the weak points of his central nervous system from his hereditary predisposition to insanity, and the uraemic poison took effect there instead of causing convulsions. 4. INSANITY OF OXALURIA AND PHOSPHATURIA. All writers on the urine have noticed the hypochondriasis, depression of mind, want of energy and originating power, and the irritability that so often go along with the presence of much oxalate of lime or phosphates in the urine. Dr. Prout 1 thought that the mental state was probably the cause of these abnormal products in the urine, and he especially mentions, "a nervous state of the system, and particularly mental anxiety and fear," as causes that, "will frequently produce in many people an excess of the salt in the urine." Golding Bird 2 says that "persons affected with 'oxaluria' are generally remarkably depressed in spirits, hypochondriacal, extremely nervous, painfully susceptible to external impressions, and in many cases labor under the impression that they are about to fall victims to con- sumption." He says, in reference to phosphaturia, that there are cases with this condition characterized by high nervous irritability, following injury to the spine. The late Dr. Begbie directed special attention to oxaluria as a cause of a nervous disorder, which was characterized by a very highly neurotic condition of the patient. He says such patients are commonly in the prime of life, belong usually to the upper classes, and have indulged freely in the good things, especially the sweets of the table. He says their sufferings often threaten their mental condition. "They are usually peevish, sensitive, and irritable, or dull and despond- ing, and melancholic." His theory of the causation of these miseries is, that they " flow from the oxalic diathesis from a poison generated during the process of digestion and assimilation, carried into the blood by the ordinary channels, but limited in its pernicious consequences by the busy agency of the urinary organs in separating it from the circulation, and discharging it from the system." Several of the cases he gives were almost insane, but I fancy fe:v such require asylum treatment. He shows that the nervous symptoms are apparently a result of the oxaluria, and disappear under the treatment that cures it. There is, on the other hand, no doubt of the fact that oxalates may be found in very great abundance in the urine of persons in good health. Lehmann, Bence Jones, and Garrod, and many others, direct special attention to this fact. The former, along with many other physicians, think that its appearance is not at all essentially connected with any special disease or train of symptoms. Speaking generally, the chemical physicians who have written on the urine take this view, while the clinical physicians take the opposite. In a very considerable number of a certain class of melancholies, the irritable hypochondriacs, we find oxalates or basic phosphates in the urine, and the special treatment suitable for those conditions as an adjunct to the moral and tonic treatment of the melancholia seems certainly to be 1 Prout p. 176, 2d ed. 2 G. Bird, pp. 250 and 307. 416 POST-FEBRILE INSANITY. useful. I think there is scarcely enough evidence to show whether this condition of the urine is a cause or an effect of the brain state. 5. THE INSANITY OF CYANOSIS FROM BRONCHITIS, CARDIAC DISEASE, AND ASTHMA. This is a form of delirium, with confusion, hallucina- tions of sight, sleeplessness, sometimes suicidal impulses, and vague fears. Those symptoms are usually worst at night, and often end in mental torpor, passing into coma. It is more commonly seen in persons of advanced age than in young people. In some degree the mental power is usually affected in most old persons who have diseases that prevent the blood being properly oxygenated. No doubt a hereditarily weak or a senile brain suffers more than a stronger brain in this way. 6. METASTATIC INSANITY. The typical rheumatic insanity is essen- tially a metastatic insanity, the diseased process leaving the joints, its normal seat, and attacking the nervous centres. I have seen more than one case where the healing of an old ulcer was followed by an attack of insanity. I have seen instances of erysipelas of the face "striking inwards" and causing an attack of acute mania. I have often seen the disappearance of a syphilitic psoriasis followed by melancholia, and its reappearance on the skin precede mental recovery. . 7. POST-FEBRILE INSANITY. The next form of insanity I shall refer to is that called by Dr. Skae post-febrile insanity. The exhaustion of the vital powers that is caused by zymotic diseases sometimes takes special effect on the higher functions of the brain, and we have an attack of in- sanity resulting. The nervous affections that often follow fevers in children are well known. These, no doubt, are precisely analogous to the post-febrile insanity of the adult. The insanity which sometimes followed fevers, was known from the earliest times, and was evidently much more common two hundred years ago than now, but it was then ascribed not to the exhausting effects of the fever, but to its not having been treated with "sufficient dilution" and purges to carry off the entire materies morbi, thus leaving a dangerous element in the system, that was liable to fly to the head and cause insanity. Arnold thought that insanity was much less common in his time than in Sydenham's after fevers and agues, because they purged more than the old physicians, and used the Peruvian bark more freely. Post-febrile insanity is not specially confined to one kind of fever. I went over the records of over a thousand cases of insanity that were sent to the Carlisle Asylum, and I found that among those there had been ten cases of such post-febrile insanity, four of which followed scarlet fever, two smallpox, one typhus, one typhoid, one intermittent, and in the tenth case I could not ascertain the exact form. Those are small numbers on which to base any conclusions in regard to a disease, but I am not aware of any fuller statistics on the subject. I think those numbers represent in a general way the comparative frequency of its occurrence after the different fevers. Scarlatina is unquestionably the most frequent cause, and smallpox the next. It is said to follow typhus more frequently than typhoid, and as intermittent fever is now very infrequent in this country, this is a very rare cause of the disease. Whether this represents the comparative exhausting powers of the POST-FEBRILE INSANITY. 417 poisons of those fevers on the brain, or whether scarlatina stands at the head of the list, from its greater frequency, or from its more common oc- currence in youth when the brain has not attained its maturity, I am unable to say with certainty. The form of insanity that results after scarlatina is almost always characterized by symptoms of dementia which are incurable. We might expect this from the well-known occurrence of idiocy and epilepsy in children after this disease of sequelae and complications. More frequently than after any other fever we hear the remark " Such a person has never been the same since he had scarlet fever." On the whole, I think there is fair ground for the assumption that the poison of this disease is more apt to leave permanent brain disease than any of the others. When mental symptoms follow the disappearance of scarlatina, they do so at once ; the patient not having an attack of acute excitement so commonly as that he is left after the disease in a state of partial dementia. The weakness of mind is not complete, but more of a partial imbecility, a blunting of all the mental faculties and affections, with attacks of sub- acute excitement and irritability. In two of my four cases there was deafness along with the imbecility, showing that the effects of the disease had not been confined to the brain convolutions, but had also affected the organs and centres of special sensation. The form of insanity that follows smallpox is of the same character as that of scarlatina, but is even more incurable. That of typhus and typhoid is more clearly the result of brain exhaustion from those diseases in cases where they have continued for a long time. The patient seems to come out of the fever, showing no particular mental symptom or in- sanity until some weeks afterwards, when he is attacked with acute ex- citement, or "gets into a low way," and a long-continued, intractable depression results. Tuke and Bucknill and Maudsley say that the in- sanity that follows typhus is of a more incurable kind than that resulting from typhoid. Sydenham describes the form of insanity that used to follow ague, and in his time this seems not to have been uncommon. He calls it a peculiar form of mania, and says that the long continuance of the fever, and of its being of a quartan type, seemed to produce the mental symptoms more than any other circumstances. If treated by the exhibi- tion of strong evacuants it degenerates into hopeless fatuity. My single case of the disease was that of a sailor, who had regular attacks of ague, drank hard, lived on salt provisions during his voyage, and on his arrival had an acute maniacal attack. He was thin, pale, and slightly scorbutic. I treated him with abundant diet, malt liquors, fresh air, quinine and iron, and a few draughts of chloral at bedtime, and he was quite well again in two months, having gained twenty pounds in weight in that tirue. In this case, of course, there were the other causes of brain ex- haustion as well as the ague. Of my ten cases only the above-mentioned patient, and one of the scarlet fever patients, had acute symptoms of any sort, and they were the only ones who recovered. All the others were incurable, six of them being hopelessly demented, and the two others hopelessly melancholic. There was hereditary predisposition to insanity in only three of the ten cases. 27 418 INSANITY FROM DEPRIVATION OF THE SENSES. Post-febrile insanity may be said, therefore, to be generally charac- terized by subacute symptoms, to result from the brain being poisoned by zymotic poison and exhausted by fever, not to require a hereditary tendency for its development, and to be a very incurable form of insanity from the beginning. I once met with a peculiar form of transient mania following an attack of erysipelas of the face in a lady, L. M., Avho, a fortnight before, had been attacked with erysipelas of the head and face of a very severe character, causing much swelling, shutting up of the eyes, and being ac- companied by slight delirium. All the acute symptoms of this had passed off, the temperature was down from 104 to normal, and the swelling of the face was abating, but still she could not open her eyes. About three days before I saw her she seemed to know that she was going out of her mind, for she asked her friends to keep her as long at home as possible before sending her away. She then began to wander in mind, and to have hallucinations of sight and hearing, to mistake identities, and to fancy she had a child. She would go on talking to imaginary people, would especially keep up long conversations with God, would ask Him quite familiarly what she was to do if any one requested her to take medicine, etc., and would fancy she got an immediate reply. Her amatory pro- pensities were exalted, and her religious feelings and emotions were both excited and perverted. Usually she lay in bed, but was at times very violent indeed. Her pulse was 86, and of fair strength, and her tem- perature 98.6. She slept little. She took liquid food. She could open her eyes slightly and with difficulty, but seldom did so, and evi- dently preferred to keep them shut, and live in her own world of fancies. Her state much resembled a waking dream. Impressions on her senses of hearing and touch were acutely felt, however, and made much im- pression often in diverting her from her unreal beliefs and hallucinations. She got stimulants with a little chloral (ten grains) at night, and next day, thinking the best way to correct her false sense impressions was to subject her to true ones, she was got out of bed, made to open her eyes, and reasoned with as to the absurdity of her fancies, and. certainly she seemed to be reasoned out of her delusions and hallucinations for the time, though she was unsettled in conversation. Her room was kept cool and well aired, and she was made to take much stimulants and nourishment. She showed a tendency to fall back once or twice into her former state, especially at night, but to a much less extent, and got quite well in a few days. I lately had a case of acute delirious mania of a very severe type fol- lowing an attack of measles in a young, strong, healthy lady. It ran a typical course, and she made a perfect recovery in a few months. 8. INSANITY FROM DEPRIVATION OF THE SENSES. I saw a gentle- man, some years ago, who became melancholic and suicidal coincidently with his loss of sight from cataract, and who improved greatly after the operation for removing it was partially successful, so that he could again see even in a dim Avay the outer world. It is very common indeed for those who are deaf to become quiet, depressed, and irritable. It is also common for such persons to become subject to hallucinations of hearing, and so insane as to need to be sent to asylums. I have now at the Royal INSANITY OF EXOPHTHALMIC GOITRE. 419 Asylum four or five such cases. It seems as if they were so cut off from the outer world by their deafness that their subjective experiences became objective realities to them. In the case of all men the senses correct many "delusions." 9. THE INSANITY OF MYXCEDEMA. I have now had three cases of myxoedema sent to my care as patients at the asylum who were positively insane, and all the examples of the disease I have ever seen were more or less affected mentally, if they were not technically insane. The first case I had sent to the asylum was L. 0., a woman of thirty-eight, whose mother was said to be "nervous," and she was said to have been "drop- sical" for' thirteen years, which no doubt was the time she had labored under myxoedema. She had become lately violent, excited, confused, and full of changing delusions, with hallucinations of hearing. On admission, she was incoherent and sleepless. Under discipline and nursing, she became more quiet and slept better, but was still confused and stupid. She was sent home after about five weeks, her symptoms having become so much better that she did not require asylum treatment, the mania and delusions having disappeared, though confusion and mental enfeeblement remained. The next case I had was the asylum plumber, L. Q., get. 54, who, having labored under myxoedema for four years, suddenly one day tried to poison himself in a deliberate reasoning way on account of a bad wife. In consequence of this and of his mental weakness he was made a patient in the asylum, but he soon got into such an improved condition that he was discharged from the books as a patient, and remains a sort of special indoor pensioner of ours, an illustration of myxoedema for the Cliniques and Medical Societies of Edinburgh. He is still alive now, after twelve years from the beginning of his disease, contented, torpid, enfeebled, suspicious, with no initiative, no temper, and no affection left for anyone, slow in his mental movements as he is in his muscles in fact, he is mildly demented. The third case is that of L. P., set. 37 on her admission to the asylum in 1878. Three years before admission she became depressed with hallucinations of smell affirming that everything smelt of gunpowder. After three years of depression, she became exalted in mind, with much excitement. Her mental condition was like that of a typical general paralytic, hilarious and facile, contented, impulsive, with delusions of grandeur, thinking her husband had lately come into a fortune. She now, after five years, is enfeebled in mind, silly in speech and conduct, very contented, with a thick, slow articulation, expression- less puffy face, with no affection and no keen desires. It seems, therefore, judging from those cases, that myxoedema always tends towards a mild dementia if it lasts long enough, and that before that occurs some patients may have maniacal and melancholic attacks. 10. INSANITY ASSOCIATED WITH EXOPHTHALMIC GOITRE. I lately had the following very interesting case, which will be more fully reported by Dr. Carlyle Johnstone, the assistant physician in charge of it : L. S., admitted into the Royal Edinburgh Asylum on the 26th of November, 1881, set. 32. She was a woi'kingman's wife, of active, steady habits, and cheerful disposition, and the mother of three children. For the last three years she had been gradually losing flesh and strength, and had latterly been treated for goitre. A few days before her admis- 420 INSANITY OF EXOPHTHALMIC GOITRE. sion she suddenly began to express delusions, and soon became intensely excited. When brought to the asylum, she was in a condition of acute excitement, writhing, struggling, and violently resisting all attempts at interference; talking incessantly, and incoherently using profane and obscene expressions, and displaying many vague and fleeting delusions. In some respects her excitement was hysterical in its character. She Avas very emaciated, and her physical condition generally was very weak. She presented the ordinary signs of exophthalmic goitre prominent eyeballs, cardiac disorder, and enlargement of the thyroid gland. There was slight elevation of the temperature, with a rapid, irregular, and feeble pulse. The maniacal condition persisted, with frequent remissions and exacer- bations, for about a couple of months, and the general health remained wretchedly poor. She was ordered tonics and the bromide of iron con- tinuously. A gradual improvement was then observed in the mental symptoms, and the relapses became less frequent and less serious. Five months after her admission, she was able to employ herself usefully in the female infirmary, and as her convalescence appeared to become estab- lished, she settled down into a steady house-worker, and behaved, except for occasional hysterical outbursts, in a sober, rational, and tolerably cheerful manner. With the abatement of the excitement, the state of nutrition became greatly improved the increase in body weight being very rapid. There was little alteration, however, in the signs of exoph- thalmic goitre, and during her residence the patient only menstruated once. In addition to these adverse symptoms, nervous phenomena of a very grave nature began to make their appearance between three and four months after admission. These began with fainting seizures, followed by a feeling of numbness in the left arm, which, in subsequent attacks, extended to the whole left side. Gradually the power of the left limbs was entirely lost, and the sense of touch disappeared from the whole of the left side, while the sense of pain was increased. The left eyeball became more prominent than the right, violent headache set in, and patient began to vomit persistently. She died on the 19th November, 1882, about twelve months after admission. The autopsy was performed thirty-six hours after death. The calva- rium, dura mater, and pia mater were considerably injected. There was great hypersemia of the left hemisphere, but in consistence and other respects that portion of the brain was tolerably healthy. The right hemisphere was very extensively diseased. Over the whole of the supe- rior and lateral aspects the pia mater was more or less firmly adherent, dragging with it, on removal, in several places, the whole depth of the cortical matter. The white matter was pink and mottled, and the cor- tical matter was universally soft and red, and in many places quite dis- organized. The optic nerves and tracts presented no abnormality; the cellulo- adipose tissue in the orbits was increased in quantity ; the thyroid gland was much enlarged ; there was a large thymus gland ; the heart was slightly hypertrophied ; the other organs were tolerably healthy. This case suggests several questions. If the extensive disease of the gray matter of the convolutions existed all the time, how was she so sane PSEUDO-INSANITY OF SOMNAMBULISM. 421 mentally for a portion of it? Was the origin of the case a vaso-motor one ? What was the relationship between the exophthalmus, the goitre, and the brain disease? 11. THE DELIRIUM OF YOUNG CHILDREN. Few mothers of large families but have had experience of the delirium of young children. Some children are much more subject to it than others. Some children, in fact, never have an increase of temperature over 99.5 without being delirious at night. In most cases it is a pure delirium without conscious- ness, attention, or memory, but in some instances there are frightful hallucinations ; in others an excited melancholia of short duration, with violent screaming, tearless weeping, and all the usual signs of mental depression. I have seen a child of six have a regular attack of melan- cholia of this character lasting for a few days. The bromides and cold to the head with hot baths are, no doubt, the best treatment, with non- stimulating nutrients like milk, and febrifuges and diaphoretics. I have known a child of eight left very melancholic after an attack of inflamma- tion of the lungs had passed off, and after the temperature had fallen to normal. 12. THE INSANITY OF LEAD-POISONING. This is a variety of mental disease which Drs. Rayner, Savage, A. Robertson, and Atkins, have quite lately 1 directed attention to. Though diseases of the nervous system from lead-poisoning have been long known to medicine, I have only seen one or two cases, and those not well marked, and complicated with alcoholism. All the cases have motor symptoms, either convulsions, or paralysis, or muscular tremblings. The mental symptoms are most various, from coma down to slight lassitude; but hallucinations, morbid elevation, maniacal attacks, delusions of persecution, have been the chief symptoms noticed in different cases. 13. POST-CONNUBIAL INSANITY. I lately had a patient, L. R., who became melancholic, suicidal, and very stupid three days after his marriage. He is now getting well. This has not unfrequently been observed. The mental excitement of marriage, culminating in an excess of sexual excitation, is liable to upset the convolutional stability in certain persons predisposed to mental disease. In my experience it has been a curable and not a prolonged form of mental disease. Some brains are so liable to be upset in their mental working, that it is no wonder the intensest known physical excitement produces this effect, just as other brains are upset in their motor centres in like circumstances and an epileptic fit occurs on each occasion of intercourse. 14. THE PSEUDO-INSANITY OF SOMNAMBULISM. One cannot admit that the actual state of somnambulism is a form of mental disease in any true or scientific sense, for the patient is necessarily asleep. But heredi- tarily it is often very closely allied to mental disease and to epilepsy, and I have ascertained that some of my insane patients had been sleep- walkers during the period of adolescence. Most bad and confirmed sleep-walkers have a neurotic heredity, or a nervous temperament, or both, though it is fortunately quite certain that few of them ever become insane. Acts of violence, homicide, and suicide may be done in a state ot 1 Journal of Mental Science, July, 1880. 422 PSEUDO-INSANITY OF SOMNAMBULISM. somnambulism. I lately saw in the Edinburgh prison a man named Simon Fraser, whose heredity was highly neurotic, who had been an aggravated sleep-walker all his life, who during his somnambulism had vivid conceptions, hallucinations, and illusions, and who in that condi- tion did all sorts of purposive acts in accordance with those false beliefs. He remembered his somnambulistic impressions in a vague way after he awoke. He was most difficult to awake. He once went up to his neck in the sea in Norway, and did not awake. At last, one night he got up, and while in a state of somnambulism, imagining he saw a white animal in the room, he seized it and dashed it against the wall. This turned out to be his child, whom he thus killed on the spot. 1 He was passionately fond of the child, and had played with it the last thing before it had gone to sleep. The question is What should be done with such a man to protect himself and others, he being perfectly sane when awake? Neither the lunacy nor the criminal laws at present make any provision for the treatment of such a state and its consequences. 1 Dr. Yellowlees has given a full account of this case and the trial in the Journal of Mental Science, vol xxiv. p. 451. LECTURE XIX. THE MEDICO-LEGAL AND MEDICO-SOCIAL DUTIES OF MEDICAL MEN IN RELATION TO MENTAL DISEASES. THE medical profession has grave medico-legal responsibilities thrown on it by the provisions of many of the forty enactments that stand on the Statute Book relating to the insane. In addition to those statutes, judges, juries, and administrators of the law constantly call in medical men to help them in the solution of questions that they only can solve. There are few things about which the British public is more sensitive than those relating to the liberty of the subject, to civil capacity, and to the control of property. In addition to these responsibilities, there are most delicate duties of a purely medical and medico-social kind thrown on our profession by the exigencies of practice, and the impossibility of finding elsewhere so qualified and wise an adviser as the family doctor. There is no doubt that all those duties should be done with much care, searching inquiry into facts, and a grave consideration of the whole effects of any opinion expressed, or of any act done ; and a special knowledge of the subject, experience, sound judgment, and caution, are all qualities requisite in dealing medico-legally with the insane. The chief medico-legal and medico-social duties of medical men in relation to mental diseases may be thus classified : 1. Taking the responsibility involved in treating cases at home, placing them under the care of attendants, advising that they be restricted as to liberty, and prevented from transacting business. This, in doubtful cases and in the early stages, of the disease, is often a very serious thing to do. The patient does not know he is ill, says in fact he is quite well, resents as an insult and a degradation being put under control, and threatens all who have to do with it with the most dire consequences. The doctor often loses the family practice after a case of insanity, whether the patient recovers or not. The only sound and safe rule for the doctor is to make it clear that he only advises and does not take any legal responsibility whatever for the steps by which a patient is controlled. Let that fall on a relation who has the legal right to take measures for the safety of the patient, and on no account be assumed by the doctor, to whom the law gives no such authority whatever but to grant certificates. If the patient is removed to lodgings to be under treatment, the relatives must do so. It need not be the nearest relative. It is often desirable to have family councils under those circumstances. Especially Avhen husbands or wives are mentally affected, some of the blood relations of the patient should, if possible, be taken into consultation. But as regards the doctor the rule is clear. Let him advise, but not act. I have even in some rare cases refused to take the responsibility of regular 424 DUTIES OF MEDICAL MEN IN attendance and treatment, without first getting a letter of protection from legal risk. The attendants in charge are the servants of the relatives, and under their order technically and legally, however much in fact they may be under the doctor's directions. In England a patient can be treated at his own home or anywhere else, if not " for profit," without certificates of lunacy, as long as his friends desire, and so long as he is not badly treated, which last procedure subjects those responsible for it to very heavy punishment. In Scotland, a patient can be treated, with a view to cure, anywhere out of an asylum for twelve months without formal certificates, if a medical opinion to that effect and intimation is sent to the Commissioners in Lunacy. I do not wish to discourage the early treatment with a view to cure of insane patients in private houses. I only point out the conditions on which only it can legally be done. 2. The most common of all the medico-legal duties thrown on medical men is that of signing the statutory medical certificates for placing patients in asylums, or under care in private houses. This is done for the proper treatment of the patient, and often for his safety as well as for the safety of the public. The form of certificate is fixed by statute, and no other form Avill do. The form is practically the same in England, Scotland, and Ireland, though the mode of placing a patient in the asylum is diiferent in the three countries. In England and Ireland a private patient can be placed in an asylum on the "order" of a relation or of anyone else after the two medical certificates have been obtained ; in Scotland the sheriff must sign the "order," after having seen the cer- tificates. Pauper patients are placed in asylums in England and Ireland on the order of a magistrate, who must see the patient, and on one medical certificate, while in Scotland pauper patients are placed in asylums in the same way as private patients, that is, on two certificates and a sheriff's order. As to the grounds on which a British subject can be legally deprived of his liberty on account of lunacy, the common law of England only recognized as a sufficient cause danger to the patient or to the public, and a recent decision seems to imply that some judges still hold that to be the law. But by the universal practice of the country, sanctioned by the Commissioners in Lunacy, the recent statutory law is taken as super- seding or supplementing the common law; and that, without defining insanity, or prescribing any specific grounds on which a patient may be detained as a lunatic, clearly enacts that "care and treatment" are the chief objects of his detention, and his being dangerous is nowhere made a sine qua non. This being so, the first thing a medical man with an insane patient who needs care and treatment in an asylum, or to be boarded with a private family, has to do, is to make up his own mind in regard to the definite grounds on which the steps are to be taken. Having done so, his next business is to convince the patient's responsible relatives of the necessity for certification. In doing this, it is far better not to press them too strongly at first if they do not see the necessity for it. All that is necessary is to explain that the responsibility rests on them, not on the doctor. It may in some rare cases be necessary, before certifying, to get a letter from a responsible person, protecting the doctor from risk RELATION TO MENTAL DISEASES. 425 of a legal action. That is a risk no medical man in signing a certificate of lunacy should subject himself to if he can help it. The lunacy statutes give exemption from actions if the facts are correct, and the certificate bona fide and correctly filled in ; and if in spite of this, under the com- mon law, actions can then be brought against medical men for doing a statutory duty in a legal way, they must just protect themselves by a letter of indemnification, or as best they can. In the case of pauper patients, the chief responsibility undoubtedly rests on the medical man, to whom the relieving officers or inspectors of poor must refer the ques- tion of asylum treatment, and must act on his opinion. In solving the question of whether a patient should be certified as a lunatic or not, the first thing, of course, to ask one's self is, " Is the patient insane?" And it is well to be prepared to say what kind of insanity he labors under. To determine this question, one must have evidence of mental disease observed by one's self, but may also use any facts proving it as ascertained from others who have seen the patient. If he is insane, then comes the further question, "Is he a proper person to be detained under care and treatment?" Many persons are insane in a medical and even in a legal sense, yet have so much self-control left, or their mental peculiarities are so slight and harmless, that they are not proper persons to be detained under care and treatment. I would say that the chief things that constitute the statutory fitness are danger to themselves or others ; disturbance of the public peace ; inability to care for and manage themselves and their affairs ; acute mental symptoms of any kind ; or amenability to curative treatment which cannot be applied without certi- fication. No doubt all sorts of considerations social, monetary, and domestic come in before determining the expediency of certification. One has to ask what are the reasons for his removal from home, where he would naturally be in sickness, and how will it affect him and his affairs generally ? Then, of course, it is proper, having determined that he should be certified, to ask what legal risk there is to yourself or to his relations. I know an undoubtedly dangerous lunatic who has kept him- self out of an asylum by bribing one member of his family by money gifts to oppose his seclusion under all circumstances, and by threatening anyone of his children who moves in the matter with disinheritance in his will. It may be necessary to see the patient several times before you can make up your mind. When those questions have been answered, and you proceed to certify, () fill in the first and purely formal part of the certificate in all cases as if it were an important business and legal document, looking at the directions on the margin. Our profession is not always sufficiently particular about this. Lawyers look on this part as of much importance. Not to designate the patient, and put in his residence at the proper place, is, according to Sir Cresswell Cresswell's judgment, to invalidate the whole document, and the English Commis- sioners always return it to the writer for correction if this is not done. The reason, no doubt, is that, there being ten thousand Thomas Jones in the country, it is necessary to discriminate clearly which one is the lunatic. In England and Ireland you must have seen the patient within a week of certification, in Scotland on the same day. 426 DUTIES OF MEDICAL MEX IN (6) Then comes the most important part of all, viz., the " facts indi- cating insanity observed by myself." Without these facts the certificate is not valid at all. By all means put in first the most evident and out- rageous insane delusions the patient labors under in as crisp and clear a way as you can. No evidence of insanity is so satisfactory to lawyers as insane delusions. Next to those in cogency come incoherence of speech, or shouting, or outrageous conduct, or loss of memory and reasoning power. Put into the certificate some of the patient's very words, if possible. Next to those come such "facts" as relate to the patient's appearance, expression of face, and manner. If you have known him before, any changes from his normal condition should be noted. By the way, in putting down delusions it is necessary often to add to a statement of one, the words " which is a delusion." Some things may be quite true, e. g., "He says he has X10,000 a year," and therefore needs this explanation. On the other hand, such delusions as "Says he is God Almighty " do not need anything of the kind. If any suicidal or homi- cidal expression can be got hold of, put it among the facts, but usually these have to come under the "facts communicated by others." Negative signs, such as absolute taciturnity, insensibility to impressions from with- out, are good enough "facts." It is better to put no "facts" that do not clearly indicate insanity, if possible, but there are some cases where the evidence must consist of lesser things than those I have mentioned put in a cumulative way, e. g., "His manner is very peculiar. He is slightly incoherent and silly in speech. His memory is impaired some- what. He has no sane interest in his affairs or in his relations or belongings. His eye is vacant in expression. His whole conversation gives me the impression that he is unfit to manage his affairs," were really all the facts observed by myself that I could put down as the results of one interview with a person of mildly enfeebled mind. It is quite pro- per to use facts observed at previous interviews, though it is better to use those at the last interview if possible. I could give instances of most ridiculous "facts" put into lunacy certificates by medical men. "He is incoherent in his appearance." "Eyes restless and wandering, but following the usual occupation of breaking stones." " She says she is in the family way (she had a baby in a few months)." " Reads his Bible, and is anxious about the salva- tion of his soul," are examples. Never put in such statements as these " He has no delusions." " His self-control is not lost." Those, in fact, prove sanity, and are not un- common. (c) The "facts indicating insanity communicated to me by others" that follow, are very important as subsidiary and not essential points of the certificate. Among them you can insert descriptions of previous aggravations of conduct and speech, of attempts or threats of suicide, or danger to others. You must put down the name of your informant. (d) The signature, residence, and dating must be carefully done. After the whole certificate is completed, I advise every man to run it over carefully. Few men are so accurate that they will not sometimes omit something. KELATION TO MENTAL DISEASES. 427 The greatest tact is necessary often to bring out the real condition of a patient's mind. This is often impossible, in fact, even when you know on good evidence that he is insane. Especially is this the case when he thinks you are a doctor come to certify him. He then naturally conceals his delusions, and puts his best foot foremost. Sometimes a little stratagem is necessary. The weak are always cunning, and it seems as if this quality was exaggerated in some insane patients. By all means get the cue to his delusions if they exist, and as full a knowledge of the patient's case as you can before you see him. I have more than once entirely failed to educe facts enough on which to found a certificate in the case of a man I knew to be insane and dangerous. I do not consider it a justifiable thing to give the patient drink in order to make him speak what is in his mind, or to bring out his peculiarities, though I have known it done more than once. 3. Medical men have to give certificates of sanity as well as of insanity sometimes. These need great care, much circumspection, and consider- able inquiry into the facts of a man's life and behavior. I have on two occasions had insane patients leave the asylum and return to me with certificates of sanity got from incautious doctors. In one case the patient produced and kept it as a good joke. It would be an awkward thing for the certifier if, after getting such a certificate, the patient went and made a will, or killed himself. In a way, a certificate of sanity needs more inquiry before it is given than a certificate of insanity. Certificates of sanity are needed to set aside a Curator Bonis, and often also before a man is allowed to resume employments and public appointments. 4. When a man is ipso facto deprived of his civil rights and the control of his property by being put into a lunatic asylum, he must have his property looked after and administered for his benefit, and another legal process has to be gone through for that purpose. In England and Ireland affidavits have to be given, stating facts indicating insanity, and especially incapacity to manage property, which are sent to the Court of Chancery, and on them, as prima facie proof, an inquisition de lunatico inquirendo is held by a "Master in Lunacy," sent to the patient's resi- dence for the purpose, at which the medical man and others have to give viva voce sworn evidence. If the patient is found lunatic, one person is appointed " Committee of the person," to control the person, and another "Committee of the estate," to manage the property, and no further certificates are needed for placing him in an asylum. This is a cumbrous and expensive, though an efficient and fair process. If the property is under JSIOOO in value, the process is simpler and cheaper. Some such process would always be necessary for doubtful and important cases, but in ninety-nine out of a hundred it is a simple, unnecessary waste of money and judicial talent. The Scotch process is far simpler and less expensive. Two doctors sign certificates "on soul and conscience" of the man's "insanity, incapacity to manage his own affairs, or to give di- rections for their management," and those are presented with a petition from a near relation, stating the amount of his property, to a judge of the Court of Session, who orders them to be intimated in a certain place in the Court for eight days, after which, if there is no opposition, a 428 DUTIES OF MEDICAL MEN IN Curator Bonis is appointed, who then manages the lunatic's property, and acts for him, after finding due caution for the proper performance of his duties. He has to present an account of his intromissions to the Court every year. The weak point of the Scotch system is, that usually no proper guardian of the lunatic's person is appointed. The nearest relative commonly acts as such. Occasionally a Curator Dative is ap- pointed to control the person, but this, with the process of " Cognition," are cumbrous, antiquated processes seldom resorted to. 5. Medical men are often called on to give evidence as to the existence or not of mental disease in persons accused of crime, to enable the law to fix or to absolve from responsibility. In Scotland the procurator-fiscal usually has a medical adviser, with a view to determine the kind of pro- ceedings to be taken in cases where crime, danger, or disturbance may have been the result of mental disease. Crime is usually committed in mania, epileptic insanity, and alcoholic insanity, and sometimes in puerperal insanity, delusional and homicidal melancholia, sometimes in dementia and congenital imbecility in an im- pulsive way, and also in impulsive insanity, where there are uncontroll- able homicidal, kleptomaniacal, pyromaniacal, destructive, or animal impulses. Some of the complications of mental disease with the effects of drunkenness are often most puzzling both to medical men and to lawyers. My experience is, that crime is usually committed at the same stage of attacks of insanity that suicides are ordinarily committed, viz., in the incipient stage. There has always been a tendency towards a divergence of view between medical men and lawyers in regard to the amount and kind of mental disease that should exempt from punishment for crime. Certainly the law has gradually come round more and more towards the medical view has, in fact, recognized the facts of nature in mental disease. Judge Tracey held that, except a criminal was irresponsible as a wild beast, he should suffer punishment. Lord Mansfield held that a "knowledge of right and wrong" was the test. The twelve judges declared in M'Naughton's case that a knowledge of right and wrong in relation to the act committed should be the true legal test ; Lord Denman said that legal responsibility should depend on the presence or absence of insane delusion ; Lord Moncrieff has laid it down that a man's habit and repute as to sanity among his fellow-men who knew him well should determine his legal responsibility for any crime committed. At last the new criminal code of Mr. Justice Stephen proposes to make the man's power of controlling his actions the test, and with that view every medical man will agree. He says " The proposition which I have to maintain and explain is, that if it is not, it ought to be the law of England, that no act is a crime if the person who does it is, at the time when it is done, pre- vented either by defective mental power or by any disease affecting his mind, from controlling his own conduct, unless the absence of the power to control has been produced by his own default." While judges during three centuries were laying down these rules of law, men that we now hold to be insane were taking away their own lives by the hundred every year, most of them knowing it to be wrong and yet doing it a "crime," KELATION TO MENTAL DISEASES. 429 and a "motiveless" one in most cases. Those suicides were surely thus exhibiting to all who had eyes to see, that, in this respect at all events, something was interfering between every natural instinct, every effort of will, and every motive of ordinary human action that something being disease and disordered function of the brain. No doubt there are many difficult cases cases on the borderland of disease, cases where vice and mental disease are mixed up puzzlingly, cases of mild enfeeblement of mind, cases of drink voluntarily taken when its effects were well known, and after being taken crime was com- mitted in a condition of delirium or short frenzy. We must admit we have no definite test as yet for detecting minute amounts of mental dis- turbance. I only wish we medical men were placed in a more satisfac- tory position before giving evidence. The whole facts on both sides are seldom put before us, and we are regarded and treated in the witness-box as partisans a position that we should resent as derogatory to science. Certainly we should never become partisans willingly. 6. We are often appealed to as to the capacity of a man to make a will, or to transact ordinary business, or to contract marriage. The principles on which our opinion should be founded for the two latter purposes are just those on which we act in determining the question of sending a patient to an asylum. In regard to will-making, great atten- tion has been directed to the subject, and there are certain fixed legal and medical principles that should be kept in mind by us. The great trouble is that we are usually not consulted at the time of making the will, when the real capacity of the testator could be examined into, but are placed in the witness-box after he is dead with one-sided, imperfect information, and with every motive operating on the side that consults us to prevent us getting at all the facts. In will-making we must enlarge our ideas of the disturbances of the mental functions of the brain beyond those com- prised under technical insanity. The senile dotard, the man exhausted in strength from disease and approaching death, the man confused in mind from fever and drink, the man distracted by terrible pain, the man whose condition is weakened so that he is made mentally unresisting and facile by disease and by the near approach of death, may all require their testamentary capacity to be tested. It is most important that a skilled and experienced medical man should be asked to examine into the testa- mentary capacity of such cases before the destination of great sums of money is irrevocably decided by a document that above all things needs soundness of judgment for its validity. It would be well were our pro- fession more called on for this purpose. I was once told by a distin- guished counsel, with a large experience in the Probate Court, that he had never known a will upset where a respectable doctor had witnessed it after examining into the testator's state of mind, and a respectable agent had drawn it up, neither of them taking any benefit under its pro- visions. It may be held as proved by legal decisions that a lesser amount of mental capacity is needed for making a valid will than for managing property or enjoying personal liberty. Patients in asylums have made good wills. Patients with insane delusions that did not affect the provi- 430 DUTIES OF MEDICAL MEN IN sions of the will have been held by the highest tribunals to have made good wills (Banks vs. Goodfellow). Very facile persons have made good wills, and those on the point of death constantly make wills that stand, while wills with the most absurd provisions have stood in law. When a medical man is asked to examine into the testamentary capa- city of a patient, he should insist on seeing the patient alone, or at all events only in the presence of a nurse or a family agent, and the first thing to be ascertained is this, (a) "Is the patient free from the influence of drink or drugs, and in his usual state?" Then (6) "Does he know the nature of the act he is to perform, and the effect of the document he is to sign?" The next thing (c) is to find out if he is not influenced in the doing of it, or in regard to any of its provisions, by insane delusion, or by an insane, morbidly enfeebled state of mind. Then (d) ascertain if there is facility of mind from bodily weakness or any other cause, or undue influence being exercised from without. Here is where you will find the benefit of being alone with the patient. I remember an old dying man confessing to me, when alone with him in these circumstances, that his niece, who was also his nurse and constant companion, was really compelling him against his judgment to make a will in her favor, his own volitional and resistive power being weakened by his state of bodily weak- ness and dependence. The influence exerted on many patients in bodily weakness, especially if it has been prolonged, by a nurse constantly in attendance, is sometimes absolutely dominant, and quite irresistible by the will of the patient. A very interesting bit of medico-psychology this is. Supposing you are satisfied so far; the next thing (e) is to make the intending testator go over the particulars of the disposition he wishes to be made, without prompting, or suggestion, or leading questions. And he should be made to do this twice, with certainly a quarter of an hour's interval between the two statements. You can then see if the disposition is a natural one, and find out from him the motives for the will being made, and for any provision of it that may seem strange. In fact, are the whole motives of action of the man quoad the will, sane, reasonable, and uninfluenced by morbid motives? Is it the act of the man himself exercising his own will spontaneously? I remember being called to see a man who was dying of bronchitis and heart disease, with his breathing impeded, his strength ebbing away, and his mental power impaired by the non-oxygenated blood supplied to his brain. He had made a will in favor of a former mistress, and was in a state of great remorse, and wanted to leave his money, which was considerable, to his relatives. But he could not twice over remember all the provisions these being a little complicated. I refused on this account on two occasions to say he had testamentary capacity. But, as sometimes happens, he became more clear in mind before death, and I was hurriedly sent for late at night to see him. He clearly went twice over the provisions he wished made in his will, and told me why he wished these made. His reasons were natural and right. The lawyer was there with the document drawn up, and the testator had just power to make his mark before he died. Yet this will was held good in law in spite of an attempt to upset it. The RELATION TO MENTAL DISEASES. 431 last thing (/) you have to ascertain is if the intending testator knows in a general way the amount of the property he has to bequeath. I lately, on getting to that point in the case of a very sensible-looking man, was astonished at being told by him that he was worth 100,000, which I knew to be quite impossible, and of course no will was made. It is most necessary not to let a good motive make us sanction a bad will, however natural its provisions may be, however much trouble or expense it may save. I am frequently asked to sanction wills being made by persons unfit to make them, on account of the convenience of having a will or the saving of expense and trouble. I have found but little realization of the impropriety or illegality of getting dying people, or those whose minds were enfeebled from paralysis, who did not really know what they were doing, to sign wills as a matter of convenience, even among conscientious reputable people. 7. The detection of feigned insanity is a duty sometimes laid on a medical man. There are no fixed rules or tests by which feigned in- sanity can be detected. I need hardly say we have first to see if the type presented is that of an ordinary kind of insanity. Most imitators mix up incoherent maniacal symptoms with silliness, and will talk no sense at all, and pretend to know nothing. In fact, they overdo their part. The patient should be carefully watched all the time, sometimes ostentatiously watched to keep him at it for a long time, and then again when he does not know he is observed. No sane man can imitate the dry skin and lips, furred tongue, constant restlessness by day and night, high temperature, and constant sleeplessness of acute delirious mania, which for a short time they often try to simulate. A man imitating the shouting, etc., of acute mania perspires freely, while an acutely maniacal patient seldom does so. The sensibility to pain should be tested, and sometimes, in prisons, a battery is found useful in the case of old crafty malingerers. I have heard of a man being put under the influence of a drug before the doctor was known to be coming, in order to produce a real stupidity with confusion of mind. I have been deceived by a clever imitator of acute mania so far as my conclusions were arrived at from one visit. I have known a really insane man assume an exaggerated insanity to make his friends think the asylum was doing him harm ; and a sort of grotesque semi-volitional imitation of mania is common in hypochondri- acal melancholies to convince their friends how ill they are; while in hysterical girls imitations of maniacal attacks and of unconsciousness are very common to excite sympathy and attract attention. 8. One of the most difficult and often most responsible duties that fall to a medical man's lot is to give confidential family advice about engage- ments to marry when one party has been insane, is threatened with insanity, or has an insane heredity, to advise as to the education and profession of children of a very neurotic heredity, and to advise as to the significance of sudden changes of conduct and sudden outbreaks of gross immorality, or of a tendency to unnatural crime, or other motive- less and unaccountable conduct in previously reputable sane people. Such advice may have the most serious consequences, blasting lives that 432 DUTIES OF MEDICAL MEN IN might have been happy. My feeling is always against the marriage of women who have been insane. I always advise young men or young women to avoid marrying into a very neurotic and insane stock, if their affections have not gone too far. The risk is very great. I agree with the French medical opinion that there is a special tendency for members of neurotic families to intermarry, and an affective affinity among such that tends towards love and marriage. That is no doubt bad for the race, and as physiologists we should try and stop it when we can. To have a neurotic young man marry a fat, phlegmatic young woman may be quite admissible, and a good safe stock may result. But what are we to say about the marriage of the neurotic, thin, hysterical young women, with insanity in their ancestry ? We know they will not make good or safe mothers. Therefore, in them we ought to discourage marriage. How- ever good its physiological effect might be on the individual, bad mental and bodily qualities, as well as tendencies to disease, are propagated to future generations. They leave the world worse than they found it thereby, the disease and therefore the misery in it being increased. The possible compensation of a genius once in a while is not to be trusted to. I believe a healthier kind of genius would result from better stock. Science, till it discovers a way of correcting such bad stock, must say, do not propagate it. A sporadic case of insanity, or of senile break- down imitating insanity, may occur in almost any family. That would not warrant any such advice about the marriage of relations as I have been giving. The relatives of such a case may all be perfectly sound. I am speaking of families in which the neurotic temperament, and espe- cially those in which the nervous diathesis, is present. If such persons are to marry, do not let them marry young, and let them marry into a sound, muscular, fat, non-nervous stock. Though the contrary has been the rule, my advice has over and again been taken, and engage- ments to marry not entered into on the ground of bad heredity. If you are asked about any young man or woman, "Is he or she likely to become insane or not?" say that science does not yet enable us to answer that question. As to the mode of education of the children of insane or neurotic parents, there can be no doubt whatever that it ought to be on physio- logical lines, and under medical advice. Such children should all be brought up in the country, and fed mostly on milk and cereals, and should have lots of fresh air, and no improper excitement, with few children's parties. They should have well-ventilated class-rooms, short school hours, and their lives and time should be systematized. Their weak points should be corrected by their modes and conditions of life. They should be kept fat, if possible, one and all. They should have no alcohol, and no tobacco till after twenty-four. At the coming on of the reproductive period of life, special care should be taken with them. The sexual appetite is most difficult to manage in them, and by them. It is often strong, disturbed, and apt to take unnatural forms, while the power of control over it is apt to be small. The occupations they choose should not imply intense head work, or a sedentary life, or excitement. Make them colonists, sending them back to nature, or get them into fixed KELATION TO MENTAL DISEASES. 433 salaried places with systematic work, and a regular holiday. The worst of it is that such persons often tend to do exactly the reverse of all this. Some especially neurotic children need very special modes of education. I have seen cases who could not safely be sent to school. Through precocious stealing, lying, and vice, they were constantly get- ting into trouble. They were without much moral sense or self-control, and had erratic, motiveless ways. I have seen good results with such children sometimes by placing them in a quiet family, under motherly care, in the country, under special rules and guidance, and away from much temptation. Such children are the stock out of which the insane, the masturbators, the dipsomaniacs, and the motiveless criminals arise, with a poet or a genius to redeem the class once in a century, and to vindicate nature's law of compensation in the world. 28 ABSTRACT STATUTES OF THE UNITED STATES, AND OF THE SEVERAL STATES AND TERRITORIES, RELATING TO THE CUSTODY OF THE INSANE. BY CHARLES F. FOLSOM, M.D., FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES; ASSISTANT PROFESSOR OF MENTAL DISEASES, HARVARD MEDICAL SCHOOL; PHYSICIAN TO OUT-PATIENTS WITH DISEASES OF THE NERVOUS SYSTEM, BOSTON CITY HOSPITAL. WITH THE ASSISTANCE OP MR. HOLLIS R. BAILEY, ATTORNEY AND COUNSELLOR-AT-LAW. GENERAL CONSIDERATIONS. THE insane asylums in the several States are, as a rule, under the direction of a board called trustees, directors, commissioners, visitors, managers, regents or administrators. These boards are in some cases elected by the legislature, more commonly appointed by the governor of the State, with or without the advice or consent of the council, or senate, or legislature. The boards are required to visit the hospitals at stated intervals, and to make annual or biennial reports to the governor or to the legislature. For the most part they appoint the medical officers of the asylums, generally with the approval of the governor. In some States the governor appoints such officers. In Maine one member of the board must be a woman, and in Iowa two may be women. In West Virginia the board is appointed by the board of public works. In Florida, Nevada, Rhode Island, and Wisconsin, the board of commis- sioners of charitable and correctional institutions is the board of trustees. In the District of Columbia the visitors are appointed by the President. In North Carolina, Tennessee, and Virginia, there are separate asylums for negroes. County asylums, where they exist, are not much better than almshouses or houses of correction for the most part : and the laws requiring them, in the few States where there are such, are often disre- garded. In Massachusetts there were never more than three, and there is now only one. The various asylums have different by-laws regarding payment of dues for patients, etc. Women are employed as physicians in some, and in one State, Nebraska, there must be one female physician. In those States where the laws do not specify regulations for the com- mitment, or admission, of private patients, the trustees are allowed to in- clude that matter under their by-laws ; and they generally prescribe a medical certificate from one physician, or two, which in some States must be signed under oath. The civil laws of all the States provide the right of habeas corpus, according to law, and the possibility of a jury trial to a person demand- ing his discharge from an insane asylum ; they deal in various ways with the disqualifications of the insane as to holding office, voting, serving as jurors or witnesses, managing property, marrying, and guardianship. In a few States incurable insanity is ground for divorce. APPENDIX, ALABAMA. 1 Patients are received at the insane asylum from the several counties of the State in proportion to the numbers of their insane population. In order of admission the indigent insane have precedence over those able to pay, and recent cases over those of long standing. Paying patients are received on the following requirements : (1) security for the payment of charges and expenses ; (2) a certificate of insanity from one or more respectable physicians ; (3) certain prescribed information as to the condition of the patient. Indigent patients are admitted only after application to the judge of the probate court in the county where the patient resides. The judge being informed that there is room for the patient at the asylum, must call one respectable physician and other witnesses, and, either with or without the verdict of a jury, at his discretion, decides the questions of insanity and indigence. The physician's certificate of insanity is taken under oath. If a paying patient, after three months, becomes indigent, and the superintendent certifies that he is a fit patient to remain, he may be re- tained at the expense of the State, on the certificate of the probate judge of his county. Indigent patients after two years' residence in the hospital, if they are not likely to be benefited by longer treatment, and are not dangerous, may be removed by order of the superintendent to the poor-house of the county of which they are resident. When a person has escaped indictment, or has been acquitted of a criminal charge, on the ground of insanity, the court shall ascertain whether the insanity in any degree continues ; in which case the court shall order the prisoner to be sent to the insane asylum. If a person, held in confinement to await trial or for want of bail, appears to be insane, the court must make an investigation, call a respect- able physician and other witnesses, and, if necessary, a jury. If it is proved that the person is insane, the court may discharge him from im- prisonment and order his removal to the hospital, where he must remain 1 Code of Alabama, 1876, g 1470-1503, 2753-2769, 2782, 2795-2799, 2802-2807, 2894, 2395, 3756, 3758, 3836, 3838, 3843. 440 APPENDIX ARIZONA. until restored to his right mind. In case of a recovery he is remanded to jail. Convicts who become insane while serving their sentence, or who are insane at the expiration of their term, if found to be suitable patients for the insane asylum, may be sent there by the Governor. A convict sent to the insane asylum who recovers before the expiration of his term of imprisonment must be returned to the penitentiary or discharged, as the Governor may order. ARIZONA. 1 (TERRITORY.) Provisions for the confinement and care of all insane persons in each county shall be made by the board of supervisors of each county, either in the county jail or in such other place as they shall think best. The Governor may make contracts for the keeping and treatment of the insane in any hospitals in the State of California. The probate judge of any county, upon an application under oath, stating that a person by reason of insanity is dangerous, shall cause the person to be brought before him for examination, shall summon two or more witnesses acquainted with the accused, and shall cause to appear one or more graduates in medicine who are also reputable practitioners. The physician or physicians shall be present during the hearing, and shall make a personal examination of the accused, and shall set forth in a written statement to be made upon oath : (1) his or their opinion as to the insanity of the party charged ; (2) whether it be dangerous to the accused, or to the person or property of others, that the accused go at large ; (3) whether such insanity is, in his or their opinion, likely to prove permanent or only temporary. The judge, if satisfied that the person is insane and unfit to be at liberty, shall make an order directing his confinement. The property of the insane person is applied, so far as it will go, to paying the expense of his commitment and maintenance. Upon proof that a person confined for insanity is no longer insane or dangerous, the probate judge may direct that he be set at liberty. The Governor shall appoint some suitable person to visit once in three months the asylums in California where there are patients from Arizona, to see that they are properly treated, and to direct the discharge of those who are sufficiently restored to reason. 1 Compiled Laws, 1877, \\ 1193-1203. APPENDIX ARKANSAS. 441 ARKANSAS. 1 Each county of the State is entitled to send to the insane asylum a certain number of patients, proportionate to the number of its inhabitants, as shown by the last census. Patients are committed to the asylum in the following manner : (1) Some reputable citizen files with the county and probate judge a written statement, certifying that the patient is a resident of the county and is, to the best of his belief, insane, and ought to be committed to the asylum for care and treatment. This statement is subscribed and sworn to before the judge, who also signs it. (2) The judge, at an appointed time, hears the testimony of the witnesses produced, and also causes an examination to be made by one or more regular practising physicians of good standing. Interrogatories, twenty-six in number, touching the habits, history, and condition of the patient are prescribed, and the physician or physicians are required to obtain answers. A sworn state- ment of the result of the examination, including the questions and answers, must be made by the physician or physicians and presented to the judge. (3) If the judge is satisfied that the person is insane and a fit patient for the asylum, he makes his decision in writing. (4) The superintendent notifies the judge whether there is room in the asylum unoccupied. If there is no room, the name of the insane person is entered on the register of the asylum, and the patient will be entitled to admission as soon as there is a vacancy. (5) If the judge receives word that there is room for the patient, he issues an order to the sheriff to take the insane person and deliver him to the superintendent of the asylum. Any insane person, a citizen of the State, whose estate will not maintain himself and his natural dependents, may be admitted to the asylum and maintained at the public expense. Insane persons having property may be admitted if there be room. Patients are classified into three classes: acute, chronic, and probably incurable. If the hospital is crowded with patients, a preference is given, in the order of admission, to the acute class, and vacancies may be made by discharging those who are probably incurable. A patient who has not recovered may be discharged and given into the care of his guardian, relatives, friends, or removed to such place as is provided for his further custody. Such removal is made by the sheriff, or his deputy, by the order of the county and probate judge. Persons who have not recovered may also be removed by their friends with the consent of the superintendent, or by the direction of the board of trustees. Patients who have recovered may be discharged by the super- intendent, but notice shall be sent to the county and probate judge, if the removal is without his order. 1 Arkansas Digest, 1874, \\ 302-326, 1227, 1228, 1828, 1966, 1988, 2001, 2002, 3488-3539, 4496-4500, 4539. Acts of the General Assembly of the State of Arkansas, 1883, pp. 2, 18-26, 150- 153, 182. 442 APPENDIX CALIFORNIA. The sheriff, of each county, before delivering any patient to the super- intendent, shall see that he or she is provided with suitable clothing to the amount prescribed. Any person attempting to commit a patient in a way contrary to the provisions of the statute, is guilty of a misdemeanor, and liable to a fine of not less than 50 nor more than $300. If a lunatic is furiously mad, so as to be dangerous, it shall be the duty of his guardian or the person in charge of him, to confine him in a suitable place until the next term of the circuit court for the county, which shall make such order for the safe keeping of the person as the circumstances of the case may require. If there is no person in charge, or if the person in charge fails to take care of such lunatic, any judge of a court of record, or any two justices of the peace of the county, may cause such insane person to be taken into custody and confined until the circuit court shall make further order. Insane persons at large shall be arrested by any peace officer and taken before a magistrate, who shall make such orders as are necessary to keep them in restraint until they can be sent by due process of law to the asylum. Insane paupers may be taken care of in the poor-house of the county. If in a criminal case, in the course of trial, or after trial and before judgment, the court shall be of the opinion that there are grounds for believing the defendant insane, all proceedings shall be postponed and a jury called to inquire whether defendant is of unsound mind. If found insane, he shall be kept in confinement in prison or in the county jail, or sent to the lunatic asylum until he is restored. If in the opinion of the court he is sane, the trial is to proceed or judgment be pronounced as the case may be. If a person is under sentence of death, and the sheriff is satisfied that there are reasonable grounds for believing him insane, he may summon a jury to try the question. If the person be found insane, the sheriff shall suspend the execution and report the case to the Governor. Persons acquitted of crime on the ground of insanity must be so reported by the jury in their verdict, and they shall be committed to the asylum by the court for further proceedings or for discharge upon their recovery, at the discretion of the court. Convicts becoming insane are not admitted to the asylum during their term of service, but are treated in the penitentiary. CALIFORNIA. 1 Patients are committed to the Stockton Asylum in the following manner : Whenever it is made to appear by affidavit to a magistrate of 1 Codes and Statutes of California, by Hittell, 1876, Vol. I. \\ 2136-2'22'J ; Vol. II. \\ 11,763-11,766, 13,361, 14,367-14,373, 14,221-14,224, 14,582'; Vol. III. \\ 14,368, 14,370, 14,373. Statutes of California, 1881, Chap. ix. ; 1883, Chaps, liv. and Ixi. APPENDIX CALIFORNIA. 443 the county that any person within the county is so far disordered in his mind as to endanger health, person, or property, he issues a warrant di- recting that the person be arrested and taken before some judge of a court of record in the county for examination. This judge summons two or more witnesses from the persons best acquainted with the insane person, and at least two graduates in medicine. The physicians must be present at the hearing and make a personal examination of the alleged insane person. The physicians must, if they believe the person dangerously insane, make a certificate stating the fact and showing, as far as possible, the nature and duration of the disease, and the age, residence, and con- dition of the patient. The judge, if he is satisfied that the person is so far insane as to endanger health, person, or property, makes an order that he be confined in the Asylum. This order is executed by the sheriff. Idiots, imbeciles, and persons affected with delirium tremens are not admitted. Commitment to the Napa State Asylum is in substantially the same manner, except that the application is made to the County Judge or to the Probate Judge of San Francisco, who conducts the examination and makes the order for commitment. Also, the physicians are especially required to ascertain Avhether the case is of a recent or curable character, and whether the insane person is of a homicidal, suicidal, or incendiary disposition, so as to be dangerous to himself or the community. There is the same provision as to idiots, imbeciles, and cases of chronic or harmless mental unsoundness, and the resident physician is directed to return such persons to the county from which they were committed. The judge shall inquire into the pecuniary ability of persons committed to the Asylum, and, if there is property sufficient to pay charges, the judgQ shall appoint a guardian to take the property and apply it to paying for the maintenance of his ward. If the insane person is indigent, but has husband or wife, father, mother, or children living within the State having means, they shall pay for his support to the extent and in the manner prescribed for paying patients. If the kindred or friends of a patient make it appear to the judge of the court who issued the commitment that they are capable of giving him proper care, the judge may issue an order for the removal of such person. No other order or application for release shall be heeded by the Trustees, except it be the order of a court or judge on proceedings in habeas corpus. If it is brought to the knowledge of the judge that a patient so removed is not properly cared for, or is dangerous for want of care, he may order such patient to be returned to the Asylum. Non-residents shall not be supported at public expense in either asylum, except temporarily if stricken while travelling in the State. The judges authorized to commit persons may send all patients to the Napa Asylum until it is filled, but may order transfers to be made from one asylum to the other, with the consent of the resident physicians of each asylum, the expense of the transfer to be paid by the guardian or friends of the patient. If doubts arise as to the sanity of the defendant in a criminal case, either during trial or before judgment, the court must order the question to be submitted to a jury, and must suspend the trial or the pronouncing 444 APPENDIX COLORADO. of judgment. If the defendant is found insane, the court must order him sent to the State Insane Asylum. If he becomes sane, the superintendent shall send word to the sheriif and district attorney, who must put the de- fendant into custody until he is brought to trial or judgment. If a person has been sentenced to death and there is good reason to believe that he has become insane, the sheriff, with the concurrence of the judge who rendered judgment, may summon a jury to inquire into the supposed insanity. The district attorney is to be notified, and is to attend the inquisition. If the defendant is found insane, the sheriff must inform the Governor, who may, when the defendant becomes sane, order execution of the judgment. When a convict, in the opinion of the physician, warden, and captain of the yard of the State Prison, is insane, they must certify the fact to the Governor, who may order the removal of the prisoner to the Insane Asylum. If the convict recovers in the Asylum, the warden of the State Prison is to be notified, and the convict is returned to the prison, if his term of imprisonment has not expired. COLORADO. 1 Until the asylum for the insane now building is ready, lunatic paupers are transported to some convenient asylum, either within or without the State limits ; the expense to be paid in the first instance by the county of which the lunatic is a resident. This expense shall be repaid the county out of the State fund. If any relatives of the lunatic, bound by law to support him, and having means, are found in the State, the money expended is to be collected of them. Whenever any reputable person shall file a complaint, duly verified, in the county court, alleging that any person is a lunatic or insane person, and that he has property, and is incapable of properly managing the same, the judge shall order a jury of six jurors to be summoned to try the question of sanity. If the jury find that such person is so insane as to be unfit to manage his property, the court shall appoint some fit per- son to be conservator of his estate. Whenever any reputable person files with the county court a complaint that any person is so insane or distracted as to be dangerous to himself or others, if allowed to go at large, the judge shall issue an order for the apprehension of such person ; provided, also, that when any sheriff or constable shall find any such insane person at large, he shall apprehend him without any order of the court. The person thus arrested shall be taken forthwith before the county court, or judge thereof, and an inquest, by six jurors, shall be 1 General Laws, State of Colorado, 1877, pp. 602-610. Session Laws of Colorado, 1879, pp. 11, 87-92; 1881, pp. 130, 141, 142; 1883, pp. 32, 33. APPENDIX CONNECTICUT. 445 held in the mode above stated. It may be held without delay, if the alleged lunatic so elect; otherwise not until at least ten days' notice has been given to him, and to a guardian, who shall be appointed for him. Until the determination of the inquest, the alleged insane person shall be con- fined in the county jail, or other convenient place. If the jury find that such person is so insane as to be unfit to go at large, the court shall commit him to the county jail or other convenient place; provided that, both before and after such inquest, if there is any relative or friend suit- able to have the custody of such alleged insane person, the county court shall order him to be delivered into the custody of such relative or friend. It is provided further that both the above-mentioned complaints may be filed at once, and one inquest held to determine both. No inquest shall be had as to the lunacy of any person charged with a criminal offence until ten days' notice has been given to the district attorney or other prosecuting officer. In case any lunatic has no relative or friend who will take care of him, the overseer of the poor-house of the county, or such other person as the county commissioners may appoint, shall have the charge of the body of such lunatic, and shall comfortably support him, at the expense of the county, unless there is property in the hands of his conservator. If there is such property, the conservator shall pay the expenses. If any person shall present to the county court an information in writing, stating that any person found by it insane has been restored to reason, the court shall cause the fact to be inquired of by a jury. If, upon such inquest, he is found restored, he shall be set at liberty, and his conservator shall return to him his property. All money expended by any county for the support or custody of lunatics shall be reimbursed to it out of the State fund. CONNECTICUT. 1 When a pauper in any town is insane, a selectman of such town applies to the judge of probate of the district where the pauper resides, asking for his admission to the insane hospital. The judge shall appoint a re- spectable physician to investigate and report the facts of the case. If the physician is satisfied of the insanity of the pauper, the judge shall order the selectman to take him forthwith to the hospital. A part of the expense of his support is paid by the town, and the balance by the State. When a person indigent, but not a pauper, is insane, any person, on his behalf, may apply to the judge of probate, who shall appoint a respectable physician and a selectman of the town where the insane 1 General Statutes of Connecticut, 1875, pp. 19, 20, 25, 56, 96-100, 536, 537. Public Acts of Connecticut, 1875-1880, pp. 25, 248, 249, 254, 327, 328, 342, 424, 452; 1881, pp. 10, 11; 1882, pp. 193, 222; 1883, p. 255. 446 APPENDIX CONNECTICUT. person resides, to investigate the case and report. If the judge is satisfied that the person is indigent and insane, he shall order him to be taken to the hospital by the person making the application. Half the expense of his support shall be paid by the town and half by the person making the application. The judge shall make a record of his orders for admission, and shall send copies of them to the Governor. Paying patients, also, may be committed to the hospital by the super- intendent, under special agreements, and comformably to law, when there are vacancies. Any sum paid by a town for the support of an insane person may be recovered from such insane person or out of his estate, if any ever comes into his possession. An insane person may be put in any suitable hospital, retreat for the insane, asylum, or place of detention, by the relatives, friends, or guardian, on the presentation of a sworn certifi- cate, made within thirty days, signed by some reputable physician, stating that he has made a personal examination within a week prior to the date thereof, and that such person is insane. This certificate and the char- acter of the signer shall be certified by an officer authorized to administer oaths. Any person thus confined may be removed by the person causing him to be detained. On a written complaint to any judge of the Superior Court that a person is insane, and unfit to go at large, the judge shall appoint a committee, consisting of a physician and two other persons, one of whom shall be an attorney-at-law, judge, or justice of the peace, who shall examine into the case, and report to the judge the facts and their opinions thereon. If, in their opinion, such person should be confined, the judge shall issue an order therefor. Any dangerous insane person at large may, by order of a justice of the peace and the first selectman of the town, on the certificate of a respectable physician of such town, be confined in some suitable place. If the person under whose care he shall be, or who is bound to support him, shall not so confine him, he shall be ordered to a suitable place by the justice and selectman. When any insane person is at large in any town, any person may complain to any selectman or justice of the peace of the town, and if he do not within three days provide for the confinement of such insane person in the manner above stated, the complainant may complain in writing, under oath, to any justice of the peace in the town, and such justice shall thereupon order a constable to bring such insane person before some justice of the peace residing in the town, who, if finding that such insane person is unfit to go at large, may order him to be confined in some suitable place for such time as he deems proper. But he may at any time, for just cause, order his discharge. And the Superior Court, on the petition of any person so confined, or of his relatives, the town to which he belongs being made a party respondent, may make any proper order with respect to his future disposal. All expenses are to be paid out of the estate of the insane person, if he has any ; if not, by his relatives liable by law to support him ; and if none such, by the town where he belongs. Persons in charge of any place of detention for the insane may dis- APPENDIX CONNECTICUT. 447 charge persons placed therein, other than criminals and such as have been sentenced, at their pleasure. The Board of Charities, consisting of three men and two women, ap- pointed by the Governor and removable at his pleasure, shall inspect all institutions in which persons are detained by compulsion, to ascertain whether inmates are properly treated, and whether any have been unjustly placed or are improperly held therein. The insane asylums shall be visited as often as once a month. Any judge of the Superior Court, on information to him that any person is unjustly deprived of his liberty by being detained in any insane asylum, or in any place for the confinement of the insane, or in any in- ebriate hospital, in the State, may appoint a commission of not less than two persons, who shall fix a time for a hearing, and shall have one or more private interviews with the person confined, and shall make due inquiries of the physicians or other persons having him in charge, and shall make a report to the judge of the facts and their opinion thereon. If, in their opinion, the party is not legally detained, or is cured, or his confinement is no longer beneficial or advisable, the judge shall order his discharge. But no commission shall be appointed as to one person oftener than once in six months. Any superior court, city court, or police court, before which a person is tried on a criminal charge, and acquitted on the ground of insanity, may order such person to be confined in the Connecticut Hospital for the Insane for such time as such court shall direct, unless some person shall give bond to the State to confine such person in such manner as the court shall order. If the insane person has any property, the court shall ap- point an overseer with the powers and duties of a conservator. If he has no estate, the expense shall be paid by the town to which he belongs ; if he belongs to no town, then by the State. Any person thus confined, or the officers of the Hospital, may petition the Superior Court of the county in which he is confined for his enlargement. The selectmen of the town to which he belongs shall be served with notice, and the State's attorney for such county shall appear, and the court shall make such order as it shall deem proper as to his disposal. If a person confined in jail upon the commitment of a justice of the peace is thought to be insane, or an idiot, the county commissioners shall appoint a reputable physician to make an examination. If the physician is of opinion that the prisoner is insane, or an idiot, he shall make a certificate to that effect and deliver it to the commissioners. The com- missioners may notify the selectmen of the town where the prisoner belongs, and they shall forthwith remove the prisoner from the jail, and provide for him in some suitable place. Dipsomaniacs, habitual drunkards, and persons addicted to the use of narcotics or stimulants, so far as to have lost their power of self-control, are treated as lunatics to the extent that the probate court may sentence them to an inebriate asylum in the State, for not less than four, nor more than twelve months, except that dipsomaniacs shall be committed for three years. 448 APPENDIX DAKOTA. DAKOTA. 1 (TERRITORY.) In each organized county there shall be a board of three commissioners call Commissioners of Insanity, two of whom shall constitute a quorum. The Judge of Probate is chairman of the board. The other two members shall be appointed by the County Commissioners. One shall be a re- spectable practising physician, and the other a respectable practising attorney. In case of the temporary absence, or inability to act, of two of the commissioners, the Judge of Probate may call in a respectable physician or lawyer to act with him. Application for admission to the Hospital must be made to the Com- missioners in writing, sworn to, stating that the person on whose behalf the application is made is believed to be insane, a fit subject for treatment in the hospital, and living within the county. His legal settlement must also be given. The Commissioners shall at once investigate the case. They may require the alleged insane person to be brought before them, or not, as they deem best. They may provide for the suitable custody of the person pending the investigation, and their warrant for the purpose shall be executed by the sheriff or any constable. They shall hear testi- mony, and any citizen or relative of the alleged insane person may appear and oppose the application. Some regular practising physician, who may or may not be of their own number, shall be appointed to make a personal examination and report whether he finds the person insane or not. The physician shall endeavor to obtain from the relatives of the person and others correct answers to certain prescribed questions, tAventy in number, relating to the patient's condition and the nature and duration of the disease. The interrogatories and answers are to be attached to the cer- tificate which the physician is required to make and give to the Commis- sioners. If the Commissioners find the person insane and a fit subject for treat- ment in the hospital, they issue a warrant authorizing the superintendent of the asylum to receive and keep the patient. The sheriff, or some other person appointed for the purpose, shall execute the warrant by delivering the patient, with a duplicate copy of the warrant and the physician's certificate, to the superintendent. If there is any relative or intimate friend of the patient who is a suitable person, he shall have the privilege of executing the warrant, if he requests it, but shall have no fee for his services. No female shall be taken to the hospital without some other female or some relative in attendance. Patients may have special care in the hospital, if the same is agreed upon and paid for in advance. The relatives or friends shall have the privilege of paying any portion or all of the expenses of a patient. If there is no room for a patient in the hospital, and he is not fit to go at large, the Commissioners shall provide for his care, either by a special 1 Revised Codes of Dakota.. 1877, p. 172. Laws of Dakota, 1879, pp. 68-86 ; 1881, pp. 98-102; 1883, pp. 298-305. APPENDIX DAKOTA. 449 custodian to be paid for by the friends or relatives of the patient, or, if he is a public patient, they shall require him to be cared for at the expense of the county by the commissioners of the county or overseers of the poor. If there is no poor-house or more suitable place, the patient may be confined in the county jail, or he may be sent to an asylum out of the Territory to be designated by the Governor. The commissioners, on application made to them, may also make provision in the county for the care of persons who are insane, but for whom admission to the hospital is not sought. The commissioners, if any insane person in the county is suffering from want of proper care, on information of the same, shall investigate the matter and make needful provision. Persons cared for outside the hospital may be transferred there by authority of the commis- sioners, when a vacancy occurs, and without further inquest, when there has been an inquest within six months. No person supposed to be insane shall be restrained of his liberty except in the way already stated, unless it be temporarily to such extent as may be necessary for the safety of persons and property, until proper authority can be obtained. Any person shall be guilty of misdemeanor who treats an insane person with wanton cruelty. If a person, confined in the hospital, is alleged to be not insane, the judge of probate, either of the county where the hospital is situated, or of the county where the patient has his settlement, upon an application alleging that the person is not insane and is unjustly deprived of his liberty, shall appoint a commission of not more than three persons, of whom one shall be a physician, and, if two or more are appointed, another shall be an attorney. They shall make examination and inquiry and report to the judge of probate. Such report shall be accompanied by a statement of the case signed by the superintendent. If the judge on this, and on the testimony offered, is satisfied the person is not insane he shall order his discharge. No commission shall be appointed in regard to the same party oftener than once in six months. If a patient escapes from the hospital, the superintendent shall notify the commissioners of insanity of the patient's county, who shall, if he be found, have him discharged or returned to the asylum, unless for good reasons they have him cared for otherwise. Any patient who is cured shall at once be discharged by the superin- tendent. The patient, if without means, shall be supplied with clothing and a sum of money not exceeding $20, to be charged with the other expenses of the patient. A patient who proves incurable, but not dan- gerous, may be removed and taken care of by his relatives, with the consent of the trustees of the hospital. The friends and relatives of a patient who is not cured, and who is dangerous to be at large, may apply to the commissioners of insanity of the county where the patient belongs, and the commissioners may have the patient removed from the hospital and cared for within the county : provided, that no patient under a charge or con- viction of homicide shall be discharged without the order of the trustees. When patients are discharged from the hospital by the authorities thereof, without application therefor, notice shall be sent to the commis- sioners of insanity of the patient's county, and they shall provide for the care of the patient unless he is discharged as cured. 29 450 APPENDIX DELAWARE. The expenses of an insane person may be collected by the county com- missioners from his estate or from the person legally bound for his support. If the hospital becomes crowded, discrimination shall be made in the reception of patients in the following order : (1) For cases of less than a year's duration. (2) For cases with favorable prospects of recovery. (3) For those for whom application has been longest on file. (4) Other things being equal, for the indigent. DELAWARE. 1 There is no State insane asylum in Delaware. Insane persons are cared for in, the county almshouse, or in some asylum in Pennsylvania selected by the Governor. Indigent lunatics or insane persons are removed to a Pennsylvania hospital in the following manner : Whenever the relatives or friends of an insane person apply to the Chancellor of the State, and present a cer- tificate of two practising physicians of the county where the insane person resides, setting forth the insanity, the cause, if known, and the necessity of better medical treatment than can be afforded in the county almshouse, the Chancellor shall, if satisfied of the insanity and indigency, recommend in writing to the Governor that such indigent insane person be removed to some asylum in Pennsylvania. But each county shall be entitled to have only five patients so supported at any one time. The expense of such support shall be paid for by each county. When a patient thus placed is cured, or is so far recovered as to be fit for removal, or for one year has shown no marked improvement, the principal physician of the hospital shall so represent in writing to the Governor of Delaware. Thereupon, the Governor shall make a written request for the patient's discharge. The Governor shall request a detailed report annually from the asylum respecting the condition and treatment of the insane from Delaware, and shall transmit it to the legislature. If any patient thus placed in a hospital becomes entitled to any property, the income of which is sufficient for his support, the Chancellor shall appoint a trustee to take charge of the same. The Chancellor may, in his discretion, require that such insane person be retained in the asylum, paying his own expenses. The trustees of the poor of the several counties, on the recommendation of the Chancellor and of the resident associate judge, shall cause any of the insane poor of their county, whether in or out of the almshouse, to be removed to any hospital for the insane in the United States, and they 1 Laws of Delaware, Kevised Code, 1874, pp. 25, 68, 233, 239, 240, 242-244, 650. Laws of Delaware, 1875, pp. 103, 104; 1881, p. 411. APPENDIX FLORIDA. 451 shall make contracts for their admission and support. The expenses shall be paid in whole, or in part, by the said trustees, so long as they judge proper. If the insane person has any property, it shall be applied to defraying the expenses of his support, whether in the almshouse or elsewhere. The overseer of the almshouse in each county shall receive and safely keep all insane persons committed to his charge by order of the levy court. When any insane person is confined in jail, the levy court may issue an order that he be placed in the almshouse ; and, if the sentence of any convict is respited on the ground of insanity, the convict may be removed to the almshouse under such order. If, in a capital trial, the defendant is acquitted on the ground of insanity, the court may, on motion of the Attorney-General, order that the defendant forthwith be committed to the almshouse of the county where the case is tried, or of the county where the insane person has his residence, or the court may order that such person be placed in any lunatic asylum in the United States. The court may appoint a trustee to contract for his commitment and support. The expenses shall be paid by the county where the offence was committed, or where the insane person has his residence ; but, if such insane person have property, it shall be applied to his support. Such insane person may be set at large by the court of general sessions of the peace and jail delivery of the county where the case was tried whenever they are satisfied that the public safety will not be thereby endangered; or the said court may order his removal from such asylum to the almshouse, either of the county where the act was committed, or of the county where he resided. If a person becomes insane, pending a civil action, the court may appoint a guardian ad litem, or the action may be continued by a trustee. . FLORIDA. 1 It is the duty of each judge of the circuit court of the State, on sug- gestion that a person is insane, to issue a writ directing the sheriff" to bring such person before him for examination. If it be found that such person is a lunatic or insane, the judge shall make such decree as is usual or necessary in such cases. If it appear that such insane person is desti- tute, the judge shall order him transported to the Asylum for the Indigent Lunatics of the State of Florida for care and custody ; or he may, in his discretion, direct the said insane person to be delivered for custody and maintenance to any other person, who shall receive not more than $150 per year for such maintenance. 1 Digest of the Laws of Florida, 1822-1881, pp. 448, 747-750. Acts and Resolu- tions of Florida, 1883, p. 64. 452 APPENDIX GEORGIA. The Comptroller, once in every six months, shall forward to the State Attorney of each circuit a list of the lunatics in the care of private persons in his circuit. The State Attorney shall cause an investigation of each case by the grand juries of the several counties, causing each of said lunatics to be brought before them. The grand jury shall make a report, a copy of which shall be sent to the Attorney-General and to the Comp- troller. The Attorney-General, where he deems it proper, shall direct the State Attorney to institute proceedings before the judge of the circuit court, looking to the change of the custody of the said lunatic, or to his final discharge, or to his transfer to the State Asylum. The physician in charge of the State Asylum may, when directed by the Board of Commissioners of State Institutions, receive into said asylum any lunatic, idiot, or insane person, whose friends, parents, or guardians are able and willing to pay for his care and support, at a rate to be fixed by the Commissioners. When any person tried for an offence is acquitted by reason of insanity, and if the discharge or going at large of such insane person shall be considered by the court manifestly dangerous, the court shall order him committed to jail, or otherwise to be cared for as an insane person ; or may give him into the care of his friends, on their giving security for his proper care; otherwise he shall be discharged. GEORGIA. 1 The State Asylum is intended for the care of lunatics, idiots, epileptics, or demented inebriates. Inmates are divided into four classes : 1. Pay or pauper patients, residents of the State. 2. Pay patients, who are non-residents. 3. Insane penitentiary convicts. 4. Insane negroes, in certain cases. Citizens of Georgia have a preference over non-residents. Resident pay patients are admitted upon authentic evidence of lunacy according to law, or by a certificate of three respectable practising physi- cians well acquainted with the condition of the patient, or a certificate from such physicians and two respectable citizens. Pay patients not resident in the State are admitted upon authentic evidence of insanity from a court having jurisdiction, or upon a certificate from their own State like that required in the State of Georgia, together with the certifi- cate of the judge having jurisdiction, that the certificates of the physi- cians and other persons are genuine and entitled to full credit. The court convicting a pauper of insanity shall certify the fact that he is a pauper. If he has any means, or becomes entitled to any property, it shall be applied, so far as it will go, to defraying his expenses. If 1 The Code of the State of Georgia, 1882, || 331(5), 1341-1374, 1658, 1852-1864, 2735, 4299, 4666, 4673. APPENDIX GEORGIA. 458 there is any one liable for his support, the amount expended may be collected of him. Otherwise he is supported at the expense of the State. Upon the petition of any person, on oath, stating that another is liable, as being a lunatic, idiot, or person non compos mentis, to have a guardian appointed, or is a fit subject to be committed to the Lunatic Asylum, the Ordinary, upon proof that ten days' notice has been given to the nearest three adult relatives of such person, or that there is no such relative within the State, shall issue a commission directed to any eighteen dis- creet persons, one of whom shall be a physician, requiring any twelve of them, including the physician, to examine the person and hear witnesses if necessary, and make a return to the Ordinary, specifying under which, if either, of said classes they find the person to come. If they find him within either of said classes, the Ordinary shall appoint a guardian for him, or commit him to the Lunatic Asylum. There may be an appeal from this finding to the superior court of the county, where the issue shall be submitted to a special jury. Guardians of insane persons are authorized to confine them or place them in the asylum, if necessary for their own protection or the safety of others. A guardian wilfully failing to do this, is liable for all injuries inflicted on others by his ward. When there is no guardian for an insane person, or the guardian, on notice, fails to confine his ward, and any person makes oath that such insane person should not longer be left at large, the Ordinary shall issue a warrant, and have the insane person brought before him on a day specified. Upon an investigation of the facts, he may commit such insane person to the Lunatic Asylum, and, if necessary, cause him to be temporarily committed to jail until he can be sent to the asylum. If a patient in the asylum appears to be incurable, but at the same time harmless, he may be discharged by the trustees of the asylum, or remanded to the care of friends and relatives. Pauper patients shall not be discharged without proper clothing and a sum of money necessary to carry them to their residence or to the county from which they were sent. If, before or after admission of a pay patient, resident or non-resident, by certificate, the alleged lunatic or his friend or relative makes a demand of the superintendent for a trial of the question of lunacy by jury, it shall be had without delay, according to law, in the county where the asylum is located. The like demand and trial may be had by all patients who have been convicted of lunacy, if the person demanding it, being a relative or friend, makes affidavit that he believes the alleged cause of commitment did not and does not exist, and that the conviction was obtained by fraud, collusion, or mistake. The same right exists also when there is an affidavit that the cause of commitment has ceased to exist, and there is a refusal by the superintendent to discharge. Provision is made for the commitment, admission, and care of in- ebriates, but only as pay patients. Insane negroes, residents of the State, are to be committed upon the certificate of the Ordinary as to their condition mentally and pecuniarily. Whenever there is an application for commitment, unattended by the requisite evidence, the superintendent may receive the person for a rea- 454 APPENDIX IDAHO. sonable time, provided payment is made in advance for his maintenance. If a person who has been once properly received as a patient has been absent so long as three months, he cannot be received back again without going through the regular process provided by law. If a penitentiary convict becomes so afflicted as to be a fit subject for the asylum, he shall be received therein upon the direction of the Gov- ernor of the State, or, if accompanied with the certificate of the physician of the penitentiary, and of the principal keeper thereof, stating the fact. Such convict shall pay for his support, if he has means. If he recovers before his term of service has expired, he shall forthwith be sent back to the penitentiary. When a person has been acquitted of a capital crime on the ground of insanity, and is committed to the asylum, he shall not be discharged except by special act of the legislature. If the crime is not capital, he may be discharged by order from the Governor. If sentence was sus- pended because of insanity, the superintendent of the asylum shall inform the presiding judge of the court where he was convicted in case of recovery. If a convict sentenced to death becomes insane, the sheriff shall sum- mon a jury of twelve men to inquire into the fact. If the jury find him insane, the presiding judge of the district shall certify the fact, and the convict shall be received into the lunatic asylum. If the patient recover, he shall be removed to the jail, and a new warrant for his execution issued. When the plea of insanity is filed, the court shall cause that issue to be first tried by a special jury, and, if found true, the defendant shall be committed to the insane asylum, and shall remain there until discharged by the general assembly. IDAHO. 1 (TERRITORY.) There is no provision as yet for an asylum for the insane in the Terri- tory of Idaho. It is made the duty of the board of county commis- sioners in each county to take care of, and provide for, the indigent sick, idiotic, and insane of the county under the regulations of law. Whenever it shall be represented to the probate judge, upon petition, under oath, by any relative or friend of any insane person, or of any person who is mentally incompetent to manage his property, the judge shall cause not less than five days' notice to be given to the supposed insane person of the time and place of hearing the case, and shall cause such person, if able to attend, to be produced before him at the hearing. If, on examination, it appears to the court that the person in question is incapable of taking care of himself and his property, the judge shall 1 Kevised Laws of Idaho, 1874 and 1876, pp. 310-318, 428, 430, 447-449, 526. Laws of Idaho, 1881, W 170, 220, 529, 530, 898. APPENDIX ILLINOIS. 455 appoint a guardian of his person and estate. Every guardian so appointed shall have the care and custody of the person of his ward, and the man- agement of his estate. If, in a capital case, after judgment of death there be good reason to suppose the defendant has become insane, the sheriff, with the concurrence of the judge who rendered judgment, may summon a jury of twelve persons to inquire into the question of the supposed insanity, and shall give notice to the district attorney. If insanity be found, the sheriff shall suspend the execution until he receives a warrant from the Governor or the judge of the court by which judgment was rendered. The Governor may appoint a day for the execution of the judgment in case of recovery. When an indictment is called for trial, or a person upon conviction is brought up for judgment, if there is a doubt as to his sanity, the court shall order the question to be submitted to the regular jury, or may order a jury to be summoned, in the way above described, to try the question. If the jury find that he is insane, the trial or judgment, as the case may be, shall be suspended until restoration to sanity; and the court, if it deem a discharge dangerous to the public peace or safety, may order a commitment to the custody of some proper person, who must detain the prisoner until he becomes sane. Upon his recovery, notice must be given to the sheriff and district attorney, and the sheriff shall, without delay, place him in proper custody until he be brought to trial or judgment, or otherwise legally discharged. The expenses of his care and custody shall be borne, in the first instance, by the county where the indictment was found ; but the amount may be recovered back from the estate of the defendant, or from any person or place bound to maintain him. ILLINOIS. 1 Preference is given to recent and curable cases, and also to patients who are violent or otherwise troublesome, when the asylums are crowded. The Board of Commissioners of Public Charities shall visit the insane hospital and other places where the insane are confined and exercise a power of supervision. They may examine persons under oath, and they shall report annually to the Governor. All patients, residents of the State, may be kept free of charge (each county paying for the support of its insane patients). If a patient is able and willing to pay for his support, he may do so. If there is room in the hospitals, residents of other States may be admitted as patients, upon the payment of the cost of their treatment. When any person is supposed to be insane, a petition is sent to the 1 Kevised Statutes of Illinois, Cothran's Annotated Edition. 1881, pp. 197-210, 363, 507, 508, 950-955, 1076. Laws of Illinois, 1881. pp. 151-153. 456 APPENDIX ILLINOIS. judge of the county court by a near relative or any respectable person for proceedings to inquire into the alleged insanity. On the filing of such petition, the judge shall have the alleged insane person brought before him at a time and place appointed for the hearing of the matter. At the time fixed for the trial, a jury of six persons, one of them a physician, shall be impanelled to try the case. The jury shall return a verdict showing the facts of the case, stating whether the person is insane, and, if so, whether fit to be sent to a State hospital. If the person is found to be insane, the court shall enter an order for his commitment to a State hospital. If the patient is not a pauper, his friends have a choice as to the hospital. The clerk of the court shall apply for the patient's admission, and, on ascertaining that he can be received, shall issue a warrant to the sheriff or some suitable person (preferring a relative, when so desired), ordering the insane person to be conveyed to the hospital. The warrant must be endorsed by the superintendent of the hospital, acknowledging the receipt of the patient and returned into court. The court, if it is necessary, pending the trial or while waiting for admission, may make such order as the case may require, for the temporary restraint of the supposed insane person, by a sheriff, jailer, or other suitable person. Idiots and persons with infectious diseases are not admitted to the hospitals. The judge of the county court is to see that pauper patients are removed from the hospital when required by the trustees. Patients not paupers are removed by their friends, who must give bonds to do so upon admission. If a patient is not removed as required, the superin- tendent may send him to the place from which he came. Whenever application is made from a patient not residing in the State, if the superintendent is of the opinion that the case is probably curable and there is room at the time in the hospital, the trustees may admit the patient, taking a bond for the maintenance of the patient, and for his removal when required. No person- shall be detained in any asylum or hospital for the insane without the order of a court of competent juris- diction, or the verdict of a jury. When any patient shall be restored to reason, he shall have the right to leave the hospital at any time, and, if detained contrary to his wishes, he shall have the privilege of a writ of habeas corpus on his own appli- cation, or on that of some one in his behalf. If a superintendent or officer of an asylum improperly receives or detains a patient, he is liable to fine not over $500 or to imprisonment for one year, and also by civil process for damages for false imprisonment. If, upon the trial of a person charged with crime, it appears that the crime was committed by the person while insane, and the jury also find that the person has not entirely and permanently recovered, the court shall cause the person to be taken to a State hospital for the insane, and there kept until fully recovered. But if the jury find that the person has entirely recovered from such insanity, he shall be discharged from custody. A person who becomes insane after the commission of a crime or mis- demeanor, shall not be tried during the continuance of the insanity ; and if after trial and verdict he becomes insane, judgment shall be arrested. If, after judgment and before execution, the defendant becomes insane, APPENDIX INDIANA. 457 then, in case the punishment be capital, the execution thereof shall be stayed until the recovery of the person from the insanity. In all these cases, the court shall impanel a jury to try the question whether the accused be at the time insane. If a convict in the penitentiary becomes insane, he shall be removed to a State hospital for the insane. If he recovers before his term of imprisonment has expired, he shall be returned to the penitentiary. INDIANA. 1 Patients are entitled to treatment, at the expense of the State, in the State asylums; but county asylums may also be provided by the county boards. Before commitment, a respectable citizen of the proper county shall, upon oath, make a statement, in writing, before a justice of the peace of the county, answering as fully as possible twenty-two prescribed interrogatories in regard to the alleged insane person's condition and history. The justice, together with another justice of the peace, and a respectable practising physician who resides in the county, and is not the medical attendant of the alleged insane person, shall immediately visit and examine the patient in relation to his mental condition. The justice of the peace shall then order the clerk of the circuit court of the county to summon the regular medical attendant of the patient, if there be one; also the person making the statement, and the persons mentioned by him in his statement as witnesses; also the selected medical examiner, and any other persons supposed to be cognizant of facts relating to the case. A hearing shall then be had, the two justices of the peace presiding. The medical attendant shall make, on oath, a written statement of the case. The medical examiner shall also make a statement, in writing, under oath, in prescribed form, saying that he has heard all the evidence, and that, in his opinion, the person is, or is not, insane. The justices of the peace shall then make a statement, in writing, if, in their judgment, the person is insane, and a fit subject for treatment in an asylum. The papers and statements are all filed with the clerk of the circuit court of the county, who forthwith applies to the superintendent of the Hospital for the Insane for the admission of the patient, accompanying the appli- cation with certified copies of the statements and certificates, unless the proper friends of the insane person prefer to place him in a private asylum within the State, when a written permission, under the seal of the court, shall be given them to do so, at their own expense. The superintendent of the hospital, on receiving the application of the clerk, shall determine from the same whether the case is recent and pre- 1 Kevised Statutes of Indiana, 1881, U 190, 1107, 1764, 1765, 2758-2782, 2835-2879, 5142-5150, 6337. Acts of Indiana, Downey's edition, 1883, pp. 1651, 1652, 1749-1752. 458 APPENDIX INDIANA. sumably curable, or chronic and less curable, or idiotic and incurable. If the case is recent and curable, the superintendent shall grant admission : if the case be chronic, whether curable or incurable, admission shall be granted, provided there be room. In the selection of chronic cases, each county is to have its due proportion, according to its population, and priority of application shall also be considered. Rejected applications may be renewed at any time within six months from the date of the inquest. No idiots are received or kept in the hospital. The clerk of the circuit court, on receiving notice that the patient will be admitted, shall have him taken to the hospital by the sheriff, or, if so desired, by some suitable person who shall be a friend or relative of the insane person. The clerk shall see that there is a proper supply of clothing for the patient, and, if the same is not otherwise furnished, it shall be paid for by the county, as also the funeral charges, if the patient dies at the hospital. Until the patient can be admitted into the hospital, the clerk shall have him taken care of, and, if necessary, may direct his confinement in the county jail. Patients restored to health are discharged by the superintendent. In- curable and harmless patients shall be discharged when it is necessary to make room for recent cases ; but all dangerous persons must be retained in the hospital. The clerk of the circuit court of the county from which the patient was sent, on notice that a patient not restored is to be dis- charged, shall issue a warrant to the sheriff to remove the patient to the proper township. Patients may be discharged, uncured, to such friends as are ready and able to take them. A patient once admitted to the hospital, or to any asylum in the State, and discharged, shall not be again admitted, except upon the affidavit of a respectable practising physician of the county where the patient resides that he knows the patient; that he has been adjudged insane; that he has been in a hospital; that he is insane, and a proper subject for treatment. He must state the reasons for his opinion. The clerk of the court shall also make a certificate that the adjudication of insanity is recorded in his office. Certified copies of these certificates will serve for an application for admission to the Hospital for the Insane or to a private asylum. If a person has been adjudged insane, and has not been admitted to the hospital within six months from the date of the inquest, the same pro- ceedings as in the case of a recommitment must be had. A transcript of the papers filed at the inquest must be sent to the superintendent, unless previously transmitted. Any person committed as insane may have a writ of habeas corpus issued, but not oftener than once in three months. When a patient is discharged as cured, the superintendent shall furnish him with clothing and a sum of money not exceeding $20, unless other- wise supplied. When complaint on oath is made before any justice of the peace that any person is insane and dangerous to the community if allowed to re- main at large, such justice shall issue a warrant for the apprehension of said insane person, and shall summon such witnesses as may be demanded by either party. The justice shall summon a jury of six reputable householders, in no way related to, or personally interested in, the APPENDIX IOWA. 459 alleged insane person or his affairs, who shall be sworn to impartially try the issue. If the jury, after hearing the evidence and examining the alleged insane person, who is to be personally present at the trial, finds that he is insane and dangerous to the community if suffered to remain at large, the justice shall appoint some resident of the county to take charge of and confine him. The person in charge shall be paid by the county, and may be changed by the county commissioners, or, if the patient is ill-treated, by the justice of the peace. The proceedings of the jury and justice of the peace must be reported to the circuit court, and at the next term thereof the issue shall be tried again by a jury of twelve persons. If they also find the person insane and dangerous, the court shall confirm the appointment of the person in charge of the insane person, or appoint some one in his place. Such insane person may be sent to the Hospital for the Insane, if a fit subject therefor. The cost of adjudging such a person insane and of caring for him shall be paid out of his property, if he has sufficient ; otherwise by the county. The court shall appoint a guardian to care for such property as is subject to the payment of his expenses. If the jury before the justice of the peace find in favor of the alleged insane person, any one may appeal to the circuit court on giving a prescribed bond. When a person tried for a public offence is acquitted on the sole ground that he was insane at the cime the offence was committed, the fact of in- sanity shall be found by the jury or by the court, and the defendant shall not be discharged, but shall be proceeded against upon the charge of insanity, in the manner prescribed for the commitment to the hospital, except that no preliminary statement in writing shall be required. IOWA. 1 There shall be in each county a board of three commissioners of insanity, including the clerk of the circuit court, who shall be clerk of the board. The other two shall be appointed by the judge of the circuit court, and shall be, one of them a respectable practising physician, and the other a respectable practising lawyer. Temporary vacancies in the board may be filled either by the judge of the circuit court, acting as a commissioner, or by the appointment of a physician or lawyer. The commissioners have cognizance of all applications for commitment to the hospital, or for the safe keeping of insane persons, except in cases other- wise specially provided for. Applications for commitment to the hospital must state upon affidavit that the person is believed by the informant to be insane and a fit subject for treatment in the hospital, and must include information as to his legal settlement. The commissioners 1 Kevised Code of Iowa, Miller, 1880, pp. 374-389; p. 1038, | 4472; p. 1044, \\ 4504, 4505; pp. 1061, 1062. Acts and Kesolutions, State of Iowa, 1882, pp. 58, 84.' ' 460 APPENDIX IOWA. may examine the informant under oath, and, if they find there is cause therefor, may proceed to an investigation. They may have the alleged insane person brought before them, if advisable, and may provide for his suitable custody pending the investigation. They shall hear such testi- mony as is offered for and against the application, and shall appoint some regular practising physician of the county to make a personal examina- tion of the patient and report thereon. He may, or may not, be of their own number. He shall make a statement certifying whether or not he finds the person insane, and, as a part of his statement, shall obtain, so far as is possible, correct answers to twenty prescribed interrogatories touching the condition and history of the patient. The commissioners shall make a finding whether or not the person is insane and a fit subject for the hospital, and where his legal settlement is, if ascertained. If the case is a proper one, they shall order the person to be committed to the hospital, unless an appeal from their decision is taken to the circuit court. If an appeal is taken, the person shall be discharged from custody pending the appeal, unless the commis- sioners find that the person cannot with safety be allowed to go at large, in which case they shall provide for his care. If, upon the trial in the circuit court, the person is found to be insane, the court shall order him to be committed to the hospital. If there is no appeal, or if, on appeal, the patient is ordered to be committed, a warrant shall issue, in the one case from the commissioners, and in the other from the clerk of the court, and the sheriff or some person appointed shall deliver the patient to the superintendent of the hospital, and along with him the physician's certificate and the finding of insanity. If any relative or friend who is a suitable person request it, he shall have the privilege of executing the warrant. If the patient is a female, there must be some other female or some relative in attendance. The superintendent shall acknowledge the receipt of the patient by a return of the warrant, which shall then be filed in court. If any person found to be insane and a fit patient for the hospital cannot at once be admitted for want of room, or for other cause, the commissioners shall have such patient suitably provided for otherwise, either as a private or a public patient. Those shall be treated as private patients whose friends or relatives will provide for them without public charge. In such cases the commissioners shall appoint some suitable person a special custodian to restrain and care for the patient. In the case of public patients, care shall be provided by the board of supervisors at the expense of the county. If there is no poor-house or more suitable place, such patients may be confined in the county jail in charge of the sheriff. The commissioners may also provide for the care and restraint within the county of insane persons, either public or private, for whom admission to the hospital is not sought. On information that any insane person is suffering for want of proper care, the commissioners shall make inquiry and, if need be, provide for the case. Persons who have been cared for outside of the hospital may, at any time within six months after the inquest, be transferred to the hospital simply on application, unless the commissioners deem further inquest advisable. On the application of the relatives or friends of an insane person in APPENDIX IOWA. 461 the hospital, who is not cured, the commissioners may authorize his dis- charge if proper provision is made for his care, but no one under a criminal charge or conviction shall be discharged without the order of the district court and notice to the district attorney. If an insane person cared for within the county out of a hospital is shown to be no longer in need of care or restraint, the commissioners shall order his immediate discharge. Any patient in the hospital who is cured shall be immediately discharged by the superintendent, who shall furnish him with suitable clothing and money not exceeding $20, unless he is otherwise supplied. The relatives of any patient who is found incurable, but not dangerous, may take charge of and remove him with the consent of the board of trustees of the hospital. The trustees, whenever it is necessary to make room, may order the removal of incurable and harmless patients, and the commissioners of the counties where they belong shall at once provide for their care. If for want of room, or for other cause, it becomes necessary to dis- criminate in the reception of patients, a selection shall be made in the following order : (1) Recent cases (of less than one year's duration). (2) Chronic cases (of more than one year's duration), presenting the most favorable prospects of recovery. (3) Those for whom application has been longest on file. (4) Other things being equal, the indigent. If a patient escapes, the superintendent shall cause search to be made, and shall notify the commissioners, who, if the patient is found, shall have him returned. Each county shall pay the expenses of its own patients, and the State shall pay for patients who have no settlement. Patients in the hospital may receive special care, if their friends make an agreement with the superintendent and pay for the same. The relatives or friends of any patient in the hospital shall have the privilege of paying any portion or all of the expenses of such patient. If an insane person has property, his estate is liable for his support, but the board of supervisors, if they deem it a hardship to take such estate, may forbear to do so, to such extent as they think just and reasonable. There shall be a visiting committee of three persons, of whom at least one must be a woman, who shall have full power to visit the hospitals, send for persons, examine witnesses under oath, discharge or prosecute employes for cause, and correct abuses. Inmates shall be allowed to write to this committee once a week and to receive letters from them, and the same shall not be opened by the superintendent or other officers. The committee shall annually report to the Governor. If it is alleged on oath that a patient is not insane and is unjustly deprived of his liberty, the judge of the district or circuit court of the county in which the hospital is situated, or of the county in which the patient has his settlement, shall appoint a commission of not more than three persons, one of whom shall be a physician, and, if two are appointed, one a lawyer. They shall go to the hospital, see the patient and examine the records and the officers, in such a manner as they deem most prudent. They shall then report to the judge the result of their inquiries, and shall get for him a written statement of the case made by the superin- tendent. If the judge finds the person not insane, he shall order his 462 APPENDIX KANSAS. discharge. This commission shall not be repeated oftener than once in six months in regard to the same party, nor appointed within six months of the time of the patient's admission. If a person charged with a crime, or under indictment, is found by the commissioners to have become insane, and to be still insane, they shall have him sent to the hospital to be kept by the superintendent. When any such lunatic is restored, he shall be again returned to jail to answer to the offence alleged against him. If a defendant be acquitted on the ground of insanity, the court must, if his discharge is considered dangerous to the public, order him to be committed to the insane hospital, or retained in custody, until he becomes sane. If a person, after conviction of a crime, becomes insane, the Governor may pardon such lunatic, or may suspend execution of his sentence and order his removal to the hospital, there to be kept until restored to reason. If a reasonable doubt arises as to the sanity of a defendant, either before trial or after conviction, the court must have a jury impanelled to inquire into the fact, the other proceedings in the case meantime to be suspended. If the jury find the defendant insane, the court, if it deems his discharge dangerous, may order his commitment to the insane hospital. If he there recovers, he shall again be put in the proper custody until brought to trial or judgment, or legally discharged. Any person who in any way treats an insane person with wanton severity, or harshness, or cruelty, or abuse, shall be guilty of a misdemeanor, and shall be liable to an action for damages. KANSAS. 1 The superintendent of one of the two asylums in the State is desig- nated by the trustees to receive all applications for commitment, and is given authority to determine to which asylum the patient shall be com- mitted. If information in writing is given to the probate court that anyone in its county is a lunatic, or a person of unsound mind, or an habitual drunkard, and incapable of managing his affairs, the court, if satisfied that there is good reason, shall cause the facts to be inquired into by a jury. It is the duty of any judge of the probate court, justice of the peace, sheriff, coroner, or constable, who discovers a person of his county to be of unsound mind, to make application to the probate court, as above stated. At the time fixed for trial, a jury of six persons, one of them a physi- cian in regular practice and good standing, shall be impanelled, and the 1 Compiled Laws of Kansas, Dassler, 1879, pp. 61, 108-111, 529-537, 584, 762,763, 883. Laws of Kansas, 1881, p. 78. APPENDIX KANSAS. 463 alleged insane person may be represented by counsel. The jury shall render their verdict in writing, embodying the substantial facts in a form prescribed, and the physician upon the jury shall make a brief medical statement of the case, so far as ascertained, and of any other circum- stances of importance. The verdict shall be recorded at large by the probate judge. If it appear that the person is insane and fit to be sent to the insane asylum, the court shall make an order for his commitment; if " of unsound mind, or an habitual drunkard, and incapable of managing his affairs," it shall appoint a guardian of his person and estate. The court may, if just cause appears at any time during the term at which the inquisition is had, set the verdict aside, and cause a new jury to be impanelled to try the case. When two juries concur in any case, the verdict shall not be set aside. If it shall be found at any time by the court, either with or without a jury, as may seem proper to the court, that the person is restored to his right mind, he shall be discharged from care and custody. If any person, by lunacy or otherwise, shall be furiously mad, so as to be dangerous, it shall be the duty of his guardian, or other person under whose care he may be, to confine him in some suitable place until pro- ceedings can be commenced in the probate court, which shall make such order as may be proper for the support and safe keeping of such person. If there is no guardian or person in charge to care for him, any judge of a court of record, or any two justices of the peace, may cause him to be apprehended, and may employ some one to confine him until the probate court shall make some order in regard to him. AVhen ;i probate judge desires to commit an insane person to the State Insane Asylum, he shall send a statement, in a prescribed form, to the superintendent, inquiring whether the patient can be admitted. Upon receiving a reply that the patient will be received, the judge shall issue his precept to the guardian, commanding him to deliver his ward into the custody of the superintendent, and at the same time give to the steward of the asylum a warrant directing him to maintain the patient. The warrant states also who is to bear the expenses, whether the county or the guardian, or some one else. To determine who is to bear the ex- pense, the probate judge shall make an examination of the property, and, if he finds that the insane person has no estate, or not more than enough to support his family, shall make a certificate to that effect, and the ex- pense of his support shall be borne by the county. Patients supported at private expense may be placed in the asylum upon application to the superintendent, if the case comes within the provisions of the asylum by-laws, and if there is room in the asylum. In every such case, the superintendent shall be presented Avith a certifi- cate, signed by at least one practising physician of the county, stating that he has examined the patient, and believes him to be insane. There .shall also be presented a certificate of the probate judge of the proper county, stating that he has appointed some one (naming him) as guardian of the patient. Questions as to the history of the case must be filled out, and forwarded to the superintendent. The person or court placing a patient in the asylum may remove such patient at any time, and the superintendent, under direction of the 464 APPENDIX KENTUCKY. trustees, may discharge any patient in accordance with the by-laws. No idiot or person with a contagious disease shall be committed to the asylum. Destitute insane persons, who have been refused admission to the asylum because of lack of room, are supported at the expense of the State. When a patient is to be discharged, the probate judge of the proper county shall be notified. If he is not restored to sanity, the judge shall issue his precept to the guardian of such person to remove him from the asylum to the proper county. If he is recovered, the steward may, under direction of the superintendent, send him, at the expense of the county or person charged with his maintenance. If a convict in the penitentiary becomes insane, the warden shall notify the prison physician, who shall, if he deem the statement true, summon to his assistance the nearest two resident physicians, and pro- ceed to make inquisition of the facts charged. If they find the person insane, they shall so certify to the warden, who shall cause the insane person to be removed to the Asylum for the Insane, there to be kept until he recovers, or is discharged by expiration of his sentence, by pardon, or by reprieve. If he recovers before his term has expired, he shall be returned to the warden. In case of a person convicted and sentenced to death becoming insane, such person shall not be executed until the Governor shall be satisfied, upon the oaths of twelve good and true men, to be named and summoned by the warden, upon proper inquiry and investigation being made, that such insanity no longer exists. KENTUCKY. 1 Each of the three asylums receives the insane of its own district, but patients may be transferred from one to another, in case any one is crowded. Negroes shall be sent only to the Eastern and Central Asylums. It is the duty of the Governor to see that each asylum has its due share of patients. If anyone be thought of unsound mind, it shall be the duty of some court of the county in which he resides, having general equity jurisdiction, upon the application of the attorney for the commonwealth, or, if he be absent, of the county attorney, to cause an inquest by a jury to be held in open court to inquire into the fact. Inquests may be held by a judge or chancellor, by the presiding judge of a county, the judge of a city court, or police judge, when no court of general equity jurisdiction is in session. The court shall appoint some member of the bar to represent 1 General Statutes of Kentucky, 1881, pp. 534-541, 642-652. Acts of Kentucky, 1881, p. 15. APPENDIX KENTUCKY. 465 the rights of the person alleged to be of unsound mind. It shall also be the duty of the attorney for the commonwealth, or for the county, to prevent any persons being improperly found of unsound mind. The jury shall take a formal oath to find truly whether the person is of unsound mind, arid, if so, whether he is an idiot, or a lunatic, what his residence is, and what property he or his parents have. If the judge who presides is of the opinion that the verdict is not sustained by the evidence, or is against law, he shall set it aside and award a new inquest. The person alleged to be of unsound mind must be in court personally before the jury, unless it shall appear by the oath or affidavit of two physicians that they have personally examined the person, and that they verily believe him to be an idiot or lunatic, as the case may be, and that his condition is such that it would be unsafe to bring him into court. Every fifth year, in the case of idiots, this inquest must be repeated to ascertain whether any change has taken place in their condition. All lunatics may be sent by order of the court to the lunatic asylum. The officer who presides at the inquest may make all orders for the security of the estate and care pending the inquest of the person found of .unsound mind. The papers pertaining to the inquest shall be filed with the clerk of the court having jurisdiction, and, at the next term thereof, a com- mittee shall be appointed and such other orders made and taken as are necessary. If a person is found a lunatic, the officer who presides at the inquest shall draw up a brief history of the patient's case embracing certain points which are enumerated in the Statutes. If the patient is delivered at the hospital within six months after the first attack of his lunacy, and the fact is certified to by the circuit judge of the district, neither the county nor any relative shall be chargeable with the cost of his detention for one year in the asylum, nor shall a relative in such case be chargeable with the cost of his transportation. Immediately on notice that a person has been ordered into confinement at the asylum the superintendent shall send for him ; but where the safety of the lunatic or others seems to require it, the court may order the patient to be carried to the asylum immediately without waiting for his being sent for. Idiots shall not be sent to the asylums, unless the jury find that they are so dangerous that they cannot be safely kept by a committee within the county. Pay patients from other States may be admitted, but not when their reception will in any way crowd the asylums so as to delay the reception of patients resident in Kentucky. No private patient who has not been found to be insane by regular inquest shall be received into either asylum. Nor shall any patient be discharged as cured, or delivered into the custody of friends, if his friends have placed him in the asylum, except by permit of the superintendent and two commissioners. A cured pauper, on discharge, shall have a good suit of clothes and be furnished with money not exceeding $20. In order to relieve the asylum from having too many patients, all pauper idiots, epileptics, and harmless, incurable lunatics shall be re- turned by the asylum to their friends or to the several counties from which they were sent. A commission, consisting of the president of the 30 466 APPENDIX LOUISIANA. board of commissioners of each asylum, the superintendent and one other of the commissioners, shall investigate and determine what patients are fit to send back. Such patients are to be taken care of either by their county committee, or by their friends, or at the expense of the State, as the case may be. Whenever it is suggested by affidavit to the court having jurisdiction, that a person found of unsound mind has been restored to his proper senses, or that the inquest was false or fraudulent, the court shall forth- with direct the facts to be inquired into by a jury in open court and make all necessary orders in the premises. Any patient charged with crime who is cured of his insanity shall be delivered to the keeper of the penitentiary or jailor of the county, as the case may require. LOUISIANA. 1 Whenever it shall be made known to the judge of the district or parish court, by the petition and oath of any individual, that any lunatic or insane person within his district ought to be sent to, or confined in, the Insane Asylum of the State, said judge shall issue a warrant to bring the insane person before him, and, after proper inquiry, if, in his opinion, he ought to be sent to the asylum, he shall have him taken there by the sheriff. The board of administrators of the asylum shall have authority to receive insane persons not sent by a district or parish judge, on such terms as they may deem fit, and money so received shall be applied to the support of the institution. All persons received in the asylum as insane shall be charged not less than $10 a month, unless the police jury of the parish from which the insane person came, a municipal council, if from a city or toAvn, or clerk of the court, shall certify that said person is in indigent circumstances. The clerk of the court, before granting such a certificate, shall summon witnesses, and make an examination, and give or refuse the certificate, as each case may require. Whenever any person arrested to answer for any crime or misde- meanor, before any court of the State, shall be acquitted by the jury, or shall not be indicted by the grand jury, by reason of the insanity of such person, and the discharge of such person shall be deemed by the court to be dangerous, the court shall commit such person to the State Insane Hospital, or to any similar institution in any parish within the jurisdic- tion of the court, there to be detained until restored to his right mind or duly discharged. The physician of the asylum shall examine the lunatic 1 Voorhies' Revised Statutes of Louisiana, 1876, pp. 427, 462-466. APPENDIX MAINE. 467 or insane person sent to the asylum by such a judge, and if, in his opinion, the person is only feigning insanity, being a person charged with a felonious crime, he shall report to the board, who shall investigate the facts, and if a majority think he should not be admitted, he shall be sent to jail, and the proper authorities notified ; and also if the prisoner is received and becomes sane while in the asylum. Any person attempting or assisting the seduction or abduction of a patient from an insane asylum shall be liable to a fine not less than $50 and not exceeding $ 500, or to imprisonment from one to six months, or to both, at the discretion of the court. MAINE. 1 The number of patients who can be accommodated in the hospital shall be apportioned among the towns according to their population. If the hospital is likely to be crowded, a preference shall be given to those towns which have not already their full proportion of patients accommo- dated. The municipal officers of towns shall constitute a board of examiners, and, on complaint in writing of any relative or justice of the peace of their town, they shall immediately inquire into the condition of any person therein alleged to be insane. The evidence, and a certificate of at least two respectable physicians, based upon due inquiry and personal examination of the person to whom insanity is imputed, shall be required to establish the fact of insanity. A certified copy of the physicians' certificate shall accompany the person to be committed. If the board of examiners think such person insane, and that his comfort and safety, and that of others interested, will thereby be promoted, they shall forthwith send him to the hospital, with a certificate stating his insanity and his residence, and directing the superintendent to receive and detain him. The examiners shall keep a record of their doings. Any person aggrieved by the decision of the board of examiners, for or against insanity, may appeal therefrom, by claiming the appeal within five days, naming a justice of the peace and quorum on his part, and appointing a time within three days thereafter, and a place in such town or an adjoining town for the hearing; the board of examiners shall select another justice of the peace and quorum. If the municipal officers applied to in the first instance neglect for three days to examine into and decide a case, or if the two justices selected on appeal neglect for three days to decide the appeal, complaint may be made by any relative of the insane, or by any respectable person, 1 Commissioners' Keport on Revision of the Laws of Maine, 1881, pp. GO, 956, 1126, 1126, 1155, 1163-1173. Special Acts and Resolves, 1883, p. 155. 468 APPENDIX MAINE. to two justices of the peace and quorum, and the justices selected in either of the above modes shall summon testimony, and hear and decide the case. If they find the person insane, and the case a proper one, they shall make a certificate for his commitment to the hospital. Such justices shall keep a record of their doings. When such justices order a commitment, the municipal officers of the town where the insane person resides, or such other person as the justices direct, shall attend to the carrying out of such order. The officers ordering ttie commitment of a person unable to pay for his support may certify to the trustees that fact, and that he has no relatives able and liable to pay for it. In such cases the State shall pay $1.50 a week for his board, and the balance shall be paid by the patient, or by the town where he resides. Parents and guardians of insane minors, if of sufficient ability to sup- port them in a hospital, shall, within thirty days after an attack of insanity, send them to the State Hospital, or to some other hospital for the insane, without any legal examination. All other persons shall be subject to examination. Any town paying for the commitment and support of an insane person may receive the amount from him, if he has property, or from the persons legally liable for his support. When any man, or any unmarried woman of twenty-one years of age, is sent to the Hospital for the Insane, the municipal officers of the town, when they think it advisable, may apply to the probate judge, and have a guardian appointed to care for any property that he or she may have, and provide for the support of the insane person and family. Patients who have no means of their own and are without relatives liable for their support, if they belong in towns having less than two hundred inhabitants, shall be supported in the hospital at the expense of the State. When any friend, person, or town, liable for the support of a patient who has been in the hospital six months, not committed by order of the Supreme Judicial Court, nor afflicted with homicidal insanity, thinks that he is unreasonably detained, he may apply to the municipal officers of the town where the insane person has his residence, and they shall inquire into the case and summon testimony, and their decision shall be -binding on the parties. If such application is unsuccessful, it shall not be made again until the expiration of another six months. At the annual meeting of the trustees, they, with the superintendent, shall make a particular examination into the condition of each patient and discharge any one so far restored that his comfort and safety, and that of the public, no longer require his confinement. The superin- tendent, at each monthly visit of the trustees, shall report to them the name of any inmate who was idiotic at the date of his commitment, and of any inmate who has become so imbecile as in his judgment to be beyond cure, and, if he thinks such inmate may be discharged with safety to him- self and to the public, the trustees shall order his discharge, and cause him to be removed by the town by which he was committed. If any person appears to have been unlawfully committed, the superintendent shall report in like manner. The Governor shall appoint a committee of visitors, consisting of two APPENDIX MAINE. 469 members of the executive council and one woman, who shall make visits as often as once a month, and shall correspond with the patients, and shall report all abuses and ill-treatment, and see that the same are properly dealt with. If the committee of visitors shall become satisfied that any inmate is wrongly committed or detained, they shall apply to the proper court for a writ of habeas corpus, and have the question determined whether such inmate is a proper subject for custody and treatment. But this shall not apply to the case of any person charged with, or convicted of, crime and duly committed by order of court. When any person is indicted for an offence, or is committed to jail on a charge thereof, any judge of the court before which he is to be tried, when he is notified that a plea of insanity is, or will be, made, may order such person into the care of the superintendent of the insane hospital, to be detained and observed by him until the further order of the court, that the truth or falsity of the plea may be ascertained. Every such person so committed shall be discharged by the superintendent if recovered, if not sent for by the court during the next term thereof after his com- mitment. When the grand jury omits to indict, or a traverse jury acquits, on account of the insanity of the accused, the court may commit the person to the insane department of the State Prison, or to the insane hospital. If committed to the insane department of the State Prison, he shall be discharged only on satisfactory proof that his discharge will not endanger the peace and safety of the community. If he is discharged and again becomes insane, any judge of the Supreme Judicial Court may recommit him to the insane department of the State Prison, or 'to the insane hos- pital. If committed in the first instance to the insane hospital, he may be discharged by any judge of the Supreme Judicial Court, if his dis- charge will not endanger the community ; or the judge may, on applica- tion, commit him to the custody of any friend who shall give bonds to the Probate Judge of Kennebec County to keep such insane person safely and pay for all damage he may do. If such person again becomes dan- gerous, any judge of the Supreme Judicial Court may recommit him to the insane hospital. When a convict is thought insane, the warden or jailor shall notify the Governor, who shall appoint two or more skilful physicians to investigate the case. If such inmate is found insane, he shall be sent to the insane hospital, to be kept there until he becomes of sound mind. If he recovers before the expiration of his sentence, he shall be returned to prison. If insane convicts prove incurable and likely to have a deleterious influence on the other patients of the hospital, the Governor and Council may remove them to the insane department of the State Prison. If an insane person is arrested on civil process, a writ of habeas corpus may be had to obtain his discharge. 470 APPENDIX MARYLAND. MARYLAND. 1 Each county is allowed in the insane hospital its due share of inmates in proportion to its population. Pay patients, to a number not exceeding seventy-five at any one time, may be received. Lunatics and insane persons are also provided with accommodations and support in the county almshouses, and in the almshouse of the city of Baltimore. A court of equity may, on the application of the trustee of a person non compos mentis, if satisfied that it is necessary and proper to confine such person, direct that he be sent to any hospital in the vicinity of the city of Baltimore, there to remain until the further order of the court. When any person is alleged to be a lunatic or insane pauper, the circuit court for the county where he resides, or the Criminal Court of Baltimore, if he resides there, shall cause a jury of twelve men to be im- panelled to inquire whether such person is insane or lunatic. If he shall be found so, the court shall cause him to be sent to the almshouse of the county or city to which he belongs, or to a hospital, or to some other place better suited to his condition, there to be confined, at the expense of the county or city, until he has recovered. But the friends or relations of such lunatic or insane person are not prevented from confining him or providing for his comfort. The county commissioners of any county may, in their discretion, re- move any lunatic pauper from the almshouse and send him to the Hospital for the Insane, and, if the quota allowed such county is already filled, the expense of such lunatic at the hospital shall be paid by the county. No person shall be supported as a pauper lunatic if he has any property, nor shall a person who is living with his parents be so supported if they have property assessed as high as $1000. Private patients are committed to an asylum, under its by-laws, upon the certificate of insanity by a regular physician, sworn to before a magistrate, and upon the request of some responsible person, who shall give bonds. If a person under indictment or charged with any offence is alleged to be insane or a lunatic, and it is found by the jury who try the case, or by a jury summoned to inquire into the insanity, that such person was insane at the time of committing the offence, and still is so, the court shall cause such person to be sent to the almshouse of the county or city to which such person belongs, to a hospital, or to some other place better suited to the condition of the prisoner, there to be confined until he has recovered his reason and has been discharged by due course of law. If, during the recess of either of said courts, any person appearing, or alleged to be, insane shall be arrested and charged with a crime, the judge shall have a jury of twelve men at once summoned by the sheriff, to try the question whether the prisoner was insane when the offence was com- mitted, and still is so. If found insane, he shall be committed as above stated. 1 Revised Code of Maryland, 1878, pp. 62, 242-244, 497-499, 660. Laws of Mary- land, 1880, p. 465. APPENDIX MASSACHUSETTS. 471 If any prisoner thus found insane has property, the income of which is sufficient to pay for his support in a hospital, the court shall appoint a trustee to take charge of such estate and to have such insane person con- fined and supported in some hospital or asylum. If any convict in the Maryland Penitentiary is insane, the Governor, on recommendation of the board of directors, may remove him and provide for his support and safe keeping in the Hospital for the Insane, or in any other State institution for the insane, and the expense shall be paid out of the funds of the penitentiary. MASSACHUSETTS. 1 A judge of the supreme judicial court, or superior court, in any county where he may be, and a judge of the probate court, or of a police, district, or municipal court within his county, may commit to either of the State lunatic hospitals any insane person then residing or being in said county, who, in his opinion, is a proper subject for its treatment or custody. Except when otherwise specially provided, no person shall be committed to a lunatic hospital, or other receptacle for the insane, public or private, without an order or certificate signed by one of said judges, stating that the judge finds that the person is insane and is a fit person for treatment in an insane asylum. The judge shall see and examine the person alleged to be insane, or shall state in his order the reason why it was not deemed necessary. The judge shall in all cases certify in what place the lunatic resided at the time of commitment. There must be filed with the judge a certificate signed by two physicians, each of Avhom is a graduate of some legally organized medical college, and has practised three years in the State, and neither of whom is connected with any hospital for the insane. Each physician must have personally examined the person alleged to be insane, within five days, and each shall certify on oath that in his opinion the person is insane and a proper subject for treatment, giving his reason therefor. A copy of this certificate shall be sent with the patient to the hospital. A person applying for the commitment of a lunatic to a State hospital shall first give notice to the mayor, or one of the selectmen of the place where the lunatic resides, of his intention to make such application. In all cases there shall be filed with the application, or within ten days after the commitment, a statement in detail in prescribed form, giving the history, habits, and condition, and the names of relatives, not exceeding ten in number, of the patient. This statement, or a copy of it, shall be sent to the superintendent of the asylum. The superintendent shall at 1 Public Statutes of Massachusetts, 1882, pp. 432-434, 471, 472, 474-482, 949, 1197, 1198, 1201, 1202, 1207, 1244. Acts and Kesolves of Massachusetts, 1882, p. 248; 1883, pp. 49, 77. 472 APPENDIX MASSACHUSETTS. once cause notice to be sent by mail to each of said relatives of the fact of the patient's admission, and also to any other two persons whom the patient shall designate. The judge, in his discretion, may apprehend the alleged insane person and place him in confinement pending examination, and may summon a jury to try the question of insanity. The verdict of the jury shall be final. If the State Board of Health, Lunacy, and Charity finds an insane person not incurable, in an almshouse or other place, in need of better treatment, it shall cause application to be made to a judge for his commit- ment to a hospital. Any person whose case is duly certified separately by two physicians, qualified as above, to be one of violent and dangerous insanity, may be received by the superintendent of any lunatic hospital and detained not exceeding five days without any warrant of commitment by a judge. In such a case there shall be an application, signed by one of the selectmen of the town, or by the mayor or one of the aldermen of the city where the insane person resides, stating that the case is one of violent and dangerous insanity, and giving the facts in regard to the patient's symptoms and history. The person committing such a person shall give a bond of $100 dollars that he will, in five days, obtain a regular order of commitment, or take the patient away. The superintendent of any insane hospital, private or public, may receive and detain therein as a boarder and patient any person who is desirous of submitting himself to treatment, and makes written applica- tion therefor, but who is not so insane as to make it proper to grant a certificate of insanity. Such patient shall not be detained longer than three days after having given notice in writing of his desire to leave. When such a patient is admitted, notice shall at once be given to the State Board of Health, Lunacy, and Charity, who shall cause the case to be investigated. Pauper lunatics having no known settlement shall be supported at the expense of the State ; other pauper lunatics by the towns or cities where their settlement is. Amounts paid by the State, or by a city or town, may be recovered of any person legally liable to support the lunatic. The attorney of a patient shall be allowed to visit him in the hospital at all reasonable times, if his visits, in the opinion of the superintendent, would not be injurious to the patient, or upon the order of a judge of the supreme, superior, or probate court. Patients shall be furnished materials to write monthly to the superintendent and to the State Board ; and locked letter-boxes shall be provided in each ward, to be opened monthly by the State Board. The State Board of Health, Lunacy, and Charity, shall have general supervision over the hospitals for the insane, public and private, and shall act as commissioners of lunacy, with power to discharge any person, whether insane or not, who is improperly restrained of his liberty, in their opinion, by reason of alleged insanity. It may discharge also such patients as can be cared for after such discharge without danger to others and with benefit to themselves. The Board may, when directed by the Governor, assume and exercise the powers of the board of trustees. Any two of the trustees of a State lunatic hospital, or any judge of the APPENDIX MASSACHUSETTS: 473 supreme judicial court, or the judge of the probate court for the county in which the hospital is situated, or in which the patient had his resi- dence, after such notice as the said trustees or judge may deem reason- able and proper, may discharge any patient, if it appears that he is not insane, or, if insane, will be sufficiently provided for by himself, his rela- tives, or friends, or by the city or town liable for his support, or that his confinement is no longer necessary for the safety of the public or his own welfare. Any two of the trustees may remove to the town or city from which he came any patient who is incurable and is not dangerous. Any person may apply to a judge of the supreme judicial court, stating that he has reason to believe that a person named is confined as insane in a lunatic hospital, or other place, public or private, and ought not longer to be so confined, and requesting his discharge. Such judge, if he thinks it proper, shall appoint a hearing and give notice of it to the superintendent, and to such other persons as he deems proper. The alleged insane person may be brought personally before the judge by a writ of habeas corpus, if it is requested, and he thinks it proper. On the request of any person interested, the question shall be submitted to a jury. If it is found by the jury, or by the judge if it is not submitted to a jury, that the person is not insane, or ought not to be so confined, he shall be discharged from such confinement. No pauper shall be discharged from a State hospital without suitable clothing, and the trustees may furnish him with a sum of money not ex- ceeding $20. The Governor or the State board may transfer inmates from one State hospital to another when it is necessary or advisable. The State board also may remove any inmate of the State Almshouse or State Workhouse to either of the State lunatic hospitals, if his condi- tion requires such transfer. But no such transfer shall be made without the certificate of two physicians, one of whom has no connection with any insane hospital, to the insanity of such inmate. Transfers from one private asylum to another, or from a private asylum to a State lunatic hospital, may be made with the consent of the State Board, but no such transfer shall be made without the consent of the legal or natural guardian of such inmate. If all the State lunatic hospitals are crowded, the trustees of any one may remove to their homes, or places of legal settlement, so many of those who are incurable and can be suitably managed at home as may be necessary to make sufficient room. Patients not furiously mad may be committed by any judge authorized to act to the county receptacle, which is required by law for each county, either within the precincts of the house of correction, or in another building to be deemed a part of the house of correction. Any insane person confined in a jail, house of correction, or county receptacle, may be removed by the Governor to either of the State lunatic hospitals, or to any other jail, or to any other suitable place, whenever it seems expedient and just. Any person committed to a county receptacle as not furiously mad may be discharged by the judge, if it appears to be for the patient's 474 APPENDIX MASSACHUSETTS. benefit, or when it appears that he can be comfortably cared for by friends or kindred. Dangerous lunatics shall not be sent to the State Almshouse. The board of trustees of any of the State lunatic hospitals may give the superintendent authority to discharge any inmate committed thereto, as an insane person, but notice of the intention to discharge must be sent by the superintendent to the person or persons who signed the petition for the commitment of such inmate. The superintendent may also, if he deem it advisable, allow inmates to leave the hospital temporarily in charge of their friends for a period not exceeding sixty days, and may receive such patients back without any further order of commitment. When a person confined in jail on civil process is supposed to be in- sane, so as to be incapable of taking the poor debtors' oath, any person interested may apply to the judge of probate for the county in which he is imprisoned. The judge shall appoint a hearing, give notice to the creditor or his attorney, and proceed with an examination into the ques- tion of insanity in the regular manner. If the person is found insane, the judge may order his discharge, or his removal to one of the State lunatic hospitals, or other place, for the confinement of insane persons. If the grand jury fail to indict a man by reason of his insanity, the court, or a judge of the supreme court, sitting for the arraignment of a person charged with murder, if satisfied that he is insane, may order him to be committed to a State lunatic hospital. When a person indicted is at the time appointed for the trial found to the satisfaction of the court to be insane, the court may cause him to be removed to one of the State lunatic hospitals. If a person convicted of a capital crime, but not yet sentenced, is found to the satisfaction of the court to be insane, he may be removed to one of the State lunatic hospitals. If a person convicted and sentenced to death appears to the satisfac- tion of the Governor and Council to have become insane, they may respite the execution from time to time, until it appears that the convict is no longer insane. A person acquitted of a crime, other than murder or manslaughter, by a jury on the ground of insanity, may be committed to an insane asylum by the court, if satisfied of the insanity. When a convict in the State Prison or Woman's Reformatory Prison appears to be insane, he may be removed, by order of the Governor, to one of the State lunatic hospitals. Such convict, however, shall first be examined by a person expert in cases of insanity appointed by the State Board of Health, Lunacy, and Charity, and also by the physician of the prison. If he recovers his sanity before his term of imprisonment has expired, he shall be reconveyed to the prison. When a convict in a house of correction or prison other than the State Prison or Reformatory Prison appears to be insane, the case shall be reported by the physician to the jailer or keeper, and by him to one of the judges authorized to act in cases of insanity, and the regular pro- ceedings shall be had for committing such person to an insane hospital. APPENDIX MICHIGAN. 475 If he recovers before the expiration of his sentence, he shall be returned to the prison or house of correction. Persons held in jail for trial or for sentence, except for a capital crime, may, if found insane, be committed to one of the State lunatic hospitals, there to remain until restored to sanity. When a person indicted for murder or manslaughter is acquitted by reason of insanity, the court shall order such person to be committed to one of the State lunatic hospitals during his life. He may be discharged therefrom by the Governor, with the consent of the council, if he becomes no longer dangerous. Any physician wilfully conspiring to commit any person who is not insane to any hospital or asylum in the State shall be punished by fine or imprisonment. Any person who establishes or keeps a private insane asylum without a license from the Governor or council, unless otherwise authorized by law, shall forfeit a sum not exceeding MICHIGAN. 1 When a person, indigent, but not a pauper, appears to be insane, application may be made to the judge of probate of the county where he resides. The judge shall appoint a time for a hearing, and notify the alleged insane person. He shall call two respectable physicians and other witnesses, and shall notify the prosecuting attorney of the county and the* supervisor of the township or ward where the insane person resides, whose duty it shall be to attend. If the judge, after a full inves- tigation, either with or without the verdict of a jury, at his discretion, shall find him insane and also indigent, he shall make a certificate, and the patient shall be admitted into the asylum and supported there at the expense of his county until he is cured, if his cure is effected within two years, and until otherwise ordered. The judge of probate shall notify the supervisors of his county of the result of the proceedings, and they shall raise the money required for the patient's support. If a pauper becomes insane, the county superintendents of the poor, or any supervisor of any city or town where the pauper belongs, shall make application to the probate judge of the county, who shall make an inves- tigation and shall call one or more respectable physicians and other witnesses, and, if satisfied of the person's insanity, shall make a certifi- cate and have him sent to the insane asylum, as in the case of a person in indigent circumstances. No insane person, not a criminal, shall be confined in any jail more than ten days, nor for any time in the same 1 Compiled Laws of Michigan, 1871, Vol. II. pp. 1482, 2167, 2168, 2178, 2196. Laws of Michigan, 1873, pp. 226, 227 ; 1877, p. 120. Howell's Annotated Statutes, Michigan, 1882, Vol. I. pp. 513-530. 476 APPENDIX MICHIGAN. room with a person charged with, or convicted of, crime. When an indigent insane person has been sent to the asylum by his friends who have paid his bills there for three months, if the superintendent certify that he is a fit patient, the supervisors of the county of his residence are required to defray the expenses of his remaining thereafter. Extra care and attendance may be allowed patients if specially contracted for. The town or county officers sending a patient to the asylum, shall pro- vide during the removal a female attendant to every female patient, unless accompanied by her husband, father, brother, or son. If a patient has no legal settlement in any county or township, the expense of his support in the asylum shall be paid by the State. The probate judge committing any indigent insane person or insane pauper shall inquire into and determine whether he has a legal settlement and where it is. The trustees of the different asylums shall meet jointly once or more each year, and may transfer patients from one hospital to another if it is necessary or desirable. So long as there is room for the insane in the wards of the State asylums, it shall be illegal to consign any insane person to the county almshouses. No patient shall be discharged without suitable clothing, and if not otherwise provided, the steward shall furnish it, and also money not exceeding $20. When a person shall have escaped indictment, or shall have been acquitted of a criminal charge or a misdemeanor on the ground of insanity, the court shall carefully inquire and ascertain whether his insanity in any degree continues, and, if it does, shall order him in safe custody and to be sent to the asylum. If any person in confinement under indictment, or sentence of impris- onment, or on any criminal process whatever, shall appear to be insane, the circuit court commissioner of the county where he is confined, or, if he be absent, the judge of the circuit court, shall upon the application of the prosecuting attorney institute an investigation and call two respectable physicians. If the insanity is proved, the commissioner or judge may order the safe custody and removal of such person to the asylum, there to remain until restored to sanity. If the patient recovers, he shall be sent back to prison to be proceeded against criminally, kept in confinement, or discharged, as the case may be. If a person imprisoned on civil process becomes insane, like proceed- ings shall be resorted to, but notice shall be given to the plaintiff or his attorney, if in the State. An insane criminal may be discharged by order of one of the justices of the supreme court or a circuit judge when, upon due investigation, it appears safe, legal, and right, to make such order. All insane soldiers and marines of the State shall be removed to the insane hospitals, and there provided for at the expense of the State. If any convict shall show symptoms of insanity while serving sentence, the warden shall give notice to the physician of the prison and to the medical superintendent of the insane asylum at Kalamazoo. They shall forthwith examine such convict, and, if they find him insane, shall certify APPENDIX MINNESOTA. 477 the fact to the warden, who shall forthwith put the convict in the insane department of the prison, and notify the Governor of his condition. The Governor shall inquire into the facts, and may order the lunatic to be conveyed to one of the State asylums for the insane. If the convict recovers his sanity before his term of sentence has expired, he shall be returned to the prison to serve out the unexpired time. If the Governor does not order the removal of such convict to the insane asylum, the physician of the prison shall give him such treatment as circumstances will permit in the insane department of the prison. If the convict so treated recovers his sanity, or so far recovers that it is safe for him to work, the warden shall put him at hard labor according to his sentence. If a convict at the expiration of his term of sentence is deemed insane, and is so certified by the physician of the prison, and none of his friends or relatives appear to take charge of him, the warden or officer in charge shall give notice to the county clerk of the county from which the convict was sent, and to one or more relatives or friends of the prisoner, and also to the probate judge of the county where the prison is located. The probate judge shall order the sheriff of the county to receive the convict on his discharge and bring him before him. The judge shall then call two respectable physicians and other witnesses, and shall notify the prose- cuting attorney of his county, whose duty it shall be to appear and act in behalf of the State. The judge shall fully investigate the facts, either with or without a jury, and, if he finds the person insane and no relative or friend ready to take charge of him, he shall send him to one of the insane asylums of the State, to be kept until restored to sanity, or taken charge of by his friends or otherwise discharged. If such person is indigent and without relatives, liable for his support, he shall be supported in the asylum at the expense of the State. \\ henever a person on trial for murder, or assault with intent to commit murder, or arson, pleads insanity, and is acquitted and found by the jury not guilty by reason of insanity, he shall be committed to the insane hospital connected with the State prison. Such person shall only be released on the certificate of the medical superintendent of the insane asylum at Kalamazoo, and the circuit judge of the court which committed him, stating that he has so far recovered as to be safe to go at large. On the filing of such a certificate with the Governor, he shall order the person to be discharged. MINNESOTA. 1 Any insane person a resident of the State may be admitted to the hospitals and maintained at the public expense, free of charge to his or her relatives or friends, and all shall be treated as public patients. The 1 Statutes of Minnesota, 1878, pp. 454-460, 598, 958. Laws of Minnesota, 1879, pp. 26, 38, 39. 478 APPENDIX MINNESOTA. probate judge, or, in his absence, the court commissioner of any county, upon information being filed before him that there is an insane person in his county needing care and treatment, shall cause the person alleged to be insane to be examined by a jury consisting of two respectable persons beside himself, one at least of whom shall be a physician, to ascertain the fact of insanity. If the person is found insane, a warrant shall issue directing that he be carried by the sheriff or some other suit- able person, and placed in the care of the superintendent of the insane hospital. It is the duty of the judge of probate, or court commissioner, with the assistance of the examining physician, to obtain, so far as possible, answers to certain prescribed questions relating to the history and condition of the patient, and to forward the same to the superinten- dent, when the patient is sent to the hospital. Patients shall be legally discharged by vote of the trustees, and, for this purpose, three shall constitute a quorum. When a patient is dis- charged as cured, the superintendent shall furnish him with suitable clothing and money sufficient to pay his expenses home, unless otherwise supplied. The relatives of any person charged with insanity or found to be in- sane shall have a right to take charge of and keep said insane person if they shall desire to do so ; but the probate judge or court commissioner may require a bond of such relatives for the proper and safe keeping of such person. If the relatives or friends of any patient kept in the hos- pital shall ask for his discharge, the superintendent may require a bond conditioned for the safe keeping of such patient : Provided, that no patient under the charge of, or convicted of, homicide shall be discharged without the consent of the superintendent and board of trustees. When- ever a patient is discharged from either asylum, the superintendent shall send notice of the same to the judge of probate who issued the warrant for the commitment. The superintendent of each hospital is required, once a month, to make out a written report of the condition of each patient in the hospital, and to send a copy to the next of kin of each of said patients. A commission appointed by the Governor, consisting of three physi- cians, of whom one shall be a member of the State Board of Health, shall visit the hospitals for the insane once in every six months, or at the request of the Governor, to examine their sanitary and general condition, and to inquire into the condition of the patients, and make a report in detail to the Governor. This commission, if they find patients whose in- sanity they have reason to doubt, may remand them to the probate courts by which they were committed, to be there detained under proper surveil- lance until the judge is satisfied of their sanity or insanity. If any patient is thus found to be sane, he shall be discharged by the probate court ; other- wise he shall be recommitted to the hospital ; but no person charged with a crime shall be so discharged. Idiots and feeble-minded children may be removed by the commissioners and sent to the Asylum for the Deaf, Dumb, and Blind, to be there treated. When any person indicted for an offence is on trial acquitted by reason of insanity, if the discharge or going at large of such person is considered by the court dangerous to the community, the court may order him to be APPENDIX MISSISSIPPI. committed to the Hospital for the Insane for safe keeping and treatment, or may order him to be committed to prison, or may give him into the care of his friends, taking bonds that he be well and securely kept. Whenever a convict in the State Prison shall, in the opinion of the warden and board of inspectors thereof, be regarded as insane, it shall be the duty of said board to call in two skilled physicians, one of whom may be the prison physician, who shall, without employing cruel or inhuman . tests, make a careful examination as to the insanity of such convict, and render a report, to be entered on the prison records. If the convict is found insane, the board shall notify the Governor, who shall have the pi-isoner sent to the insane hospital, there to be kept and treated. If such a patient is cured of the mental disability on account of which he was committed to the hospital, and his term of sentence has not expired, the Governor shall be notified, and the convict shall be remanded to the State Prison. MISSISSIPPI. 1 Any person, being a lunatic and a resident of the State, may be ad- mitted into the asylum free of charge, the expenses of removal to be paid by the county from which the insane person was sent, or in which he had his settlement; but if the patient is able, he shall pay for the expense of his removal. The superintendent of the asylum, provided there is room, shall admit all persons ordered to be placed therein by the chancery court after an inquest of lunacy. When an application is made by the friends or relatives of a lunatic to the chancery court, if the court is satisfied there is probable cause, it shall order the sheriff to summon the person alleged to be of unsound mind, and six good men of the county in no way related to the party, to try the question of insanity. If the person is judged by the inquest, or a majority of them, to be incapable of taking care of himself, they shall certify the same to the court, and the court or chancellor, or clerk in vacation, shall appoint some suitable person guardian of such lunatic, directing the guardian to take care of the person and his estate. If the case requires it, the court or clerk may direct confinement in the lunatic- asylum. In case the friends or relations of any lunatic shall neglect or refuse to place him in the asylum, and shall allow him to go at large, the clerk of the chancery court of any county in which such lunatic may reside or be found going at large, on the suggestion, in writing, of any citizen, shall direct the sheriff to summon the lunatic and six discreet persons to make inquisition. If the person is adjudged by the inquest, or a 1 Revised Code of Mississippi, 1880, pp. 205-210, 581-583, 794, 795, 802, 803. Laws of Mississippi, 1882, pp. 61-65. 480 APPENDIX MISSOURI. majority of them, to be insane, and a fit subject for the asylum, the clerk shall order the sheriff to take the lunatic and place him in the asylum, if there be a vacancy, or, if there be no vacancy, to confine him in the county jail until room can be had in the asylum. If any patient is found incurable, but harmless, the superintendent shall have him removed to the county where he belongs, there to be cared for by his guardian or his friends, or, if he is poor and has no friends who are able, he shall be maintained as a poor person by the county. If the superintendent and trustees think that a lunatic who is a resi- dent of the State ought to be admitted as a patient, they may receive him, even though no proceedings in lunacy have been instituted. The trustees may adopt such rules as they think proper in regard to requiring a statement of the case and a history of the patient, to be presented with the application for admission. When a person is charged with the commission of an offence, and it appears that he was insane when the offence was committed, and still is insane, he shall not be discharged, but the case shall be reported to the chancellor or clerk of the chancery court of the proper county, whose duty it shall be to proceed with the case according to the law relating to persons non compos mentis. When the grand jury fails to indict, or a traverse jury fails to convict, a person by reason of his insanity, and it is found that the person is still insane and dangerous, notice shall be given to the proper chancellor or clerk of the chancery court, whose duty it shall be to proceed with such person and his estate according to the law relating to insane person. If the sheriff is satisfied that any convict under sentence of death is insane, he shall, with the concurrence of the judge of the circuit court, or the chancellor, or the president of the board of county supervisors, in the absence of such circuit judge, summon six physicians, if to be had, and, if not, six other discreet men, to inquire into such insanity. If the convict is found insane, the verdict shall be transmitted to the Governor, and the execution suspended until the Governor is satisfied that the convict has become sane. MISSOURI. 1 Persons afflicted with any form of insanity may be admitted into an insane asylum when the superintendent thinks they will be benefited by the care and treatment of the institution ; and any patient may be dis- charged by the superintendent if longer treatment is not likely to improve his condition. The indigent insane of the State shall always have the preference over those who have the ability to pay, and, if there is not 1 Revised Statutes of Missouri, 1879, Vol. I. p. 325; Vol. II. pp. 818-828, 1133, 1138. Laws of Missouri, 1881, pp. 123, 141 ; 1883, pp. 78, 79. APPENDIX MISSOURI. 481 room in the asylum for all the insane persons in the State, recent cases (of less than a year's standing) shall have the preference ; but no county shall have in the institution more than its just proportion, according to its insane population. There shall be sent with each patient a detailed account of his case, as far as practicable, stating the cause of his insanity, its duration, the former treatment of the patient, and all other particu- lars; and, if possible, some one acquainted with the individual should accompany him to the asylum, from whom minute particulars of his in- sanity may be learned. Pay patients, those not sent by order of the court, are admitted as follows : The superintendent shall be furnished with a request in a pre- scribed form, and with a certificate, dated within two months, in pre- scribed form, signed by two physicians, stating the patient to be insane. Thirty days' charges must be paid in advance, and a sufficient bond given in prescribed form to secure future expenses, and the removal of the patient when desired. County patients are admitted as follows : The several county courts shall have power to send to the asylum such of their insane poor as may be entitled to admission. The counties thus sending shall pay semi- annually, in cash, in advance, for the support of their insane poor, the price of board to be fixed by the board of managers. Some citizen in the proper county must file with the clerk of the county court a state- ment, in prescribed form, that the person is insane and a recent case, and has no property. It shall give the names of two witnesses who can swear to the facts, one of whom shall be a respectable physician. The clerk shall thereupon summon the witnesses named to appear at a speci- fied time, also such other persons as he thinks proper. At the time appointed, unless there is an adjournment, there shall be a trial before the court, either with or without a jury. If the facts stated shall be found true, an order shall be entered of record, stating that the person found to be insane is a fit subject for treatment in the asylum. The order shall require the medical witness to make out a detailed history of the case, and also that the clerk of the court make application to the superintendent of the asylum for the patient's admission. If the patient is dangerous to be at large, that fact shall be set forth. The superintendent, on receiving the application and a copy of the order of the court, shall immediately advise the clerk whether the patient can be received, and, if so, at what time. If the patient can be admitted, the clerk shall issue his warrant to the sheriff' or some suitable person, the relatives of the insane person having a pref- erence, directing that the insane person be arrested and conveyed to the State Lunatic Asylum. If there is necessity, he may authorize one or more assistants. The superintendent shall acknowledge on the writ the receipt of the patient, and the warrant shall be returned into court. A pay patient may become a county patient, if the county court so order. In such case, the clerk of the court shall send to the superinten- dent a certificate, stating that the patient has not estate sufficient to support him in the asylum. A county patient may become a pay patient by order of the county court, and the filing of the proper certificate, stating the ability of the patient to pay. 31 482 APPENDIX MISSOURI. Whenever the superintendent desires the removal of a county patient from the asylum, he shall notify the clerk of the county court of the county from which such patient was sent, and the clerk shall have the patient removed by the sheriff. If any person, by lunacy or otherwise, shall be furiously mad or dangerous, it shall be the duty of his guardian, or other person under whose care he may be, to confine him in some suitable place until the next sitting of the probate court for the county, when such order shall be made by the court for the restraint, support, and safe keeping of the person, as the circumstances of the case shall require. If the persons in charge of such an insane patient fail to confine him, or if there is no one in charge of him, any judge of a court of record, or any two justices of the peace, may cause him to be apprehended, and may employ some one to confine him in a suitable place until the probate court makes such further orders as the case may require. When a person tried upon indictment for any crime or misdemeanor shall be acquitted on the sole ground that he was insane when the offence was committed, the fact shall be found by the jury in their verdict, and also whether the prisoner has recovered or not. If the prisoner has recovered, he shall be discharged. If he has not recovered, and is not a poor person, and the court is satisfied it would be unsafe to permit him to go at large, the court shall order that he be sent to the asylum. The sheriff shall keep such prisoner in the county jail, poor-house, or other safe custody, until such time as he can be received into the asylum, and then shall transfer him there. The costs and the expense of maintaining such insane person shall be taxed by the court each term, and collected out of the prisoner's estate. If the prisoner is a poor person, the court shall order him to be kept in safe custody by the sheriff until the county court shall cause him to be removed to the asylum, as in the case of insane poor persons ; provided, however, that ho further examination into the insanity of the prisoner need be made. By an indigent or poor insane person is meant one who is worth, above his debts, and excluding property exempt from execution, less than $300 : or, if he has a family, less than $ 1000, after deducting out also the expense of supporting his family for one year. If any convict, before the execution in whole or in part of the sentence of the court, becomes insane, it shall be the duty of the Governor to inquire into the facts ; and he may pardon such lunatic, or commute the execution, and may order such lunatic to be conveyed to the asylum, and there kept until restored to reason. If the sentence is only suspended for a time, it shall be executed -at the expiration of the period, unless the Governor direct otherwise. If any person, after indictment and before trial, becomes insane, the circuit or criminal court wherein such person stands charged shall suspend proceedings, and order a jury to be sum- moned to try the question of the insanity of the person. The judge shall notify the prosecuting attorney of the inquiry, and also the alleged insane person, unless the court order him to be brought before it. If the jury find that the person has become insane, the judge shall order him to be sent to the lunatic asylum. If he ever recovers his sanity, the proceed- ings against him shall go on as if there had been no interruption. If the APPENDIX MONTANA. 483 jury find that he has not become insane, then the trial shall go on in the same manner as though no such inquiry had been made. If, after any convict is sentenced to the punishment of death, the sheriff has cause to believe that he has become insane, he may summon a jury of twelve men, and give notice to the prosecuting attorney, and have the question tried. If it is found that such convict is insane, the sheriff shall suspend the execution until he receives a warrant from the Governor or the court, directing him to proceed with the execution. MONTANA. 1 (TERRITORY.) There being as yet no public insane asylum established, the commis- sioners of the insane are authorized to make a contract with some person to take charge of and care for insane persons who shull be delivered to him. The Governor also may make contracts for the care of the indigent insane of the Territory, and may pay the expense of sending patients out of the Territory to their friends if he deem it advisable. It is the duty of the probate judge, or, in his absence or inability to act, of the chairman of the board of county commissioners of the several counties (upon the application of any person, under oath, stating that any person, by reason of insanity, is unsafe to be at large, or is suf- fering from mental derangement), to cause such person to be brought before him, and also a jury of three citizens of his county, one of whom shall be a licensed practising physician. A hearing shall be had by the jury, and an examination shall be made of the alleged insane person. If the jury, after a careful examination, certify that the charge is correct, and the probate judge or commissioner is satisfied that such person, by reason of insanity, is unfit to be at large, or is incompetent to provide for his own proper care and support, and has no property, and no near kindred of sufficient means to provide for such maintenance, or if such kindred neglect and refuse to care for him, then the judge or county commissioners shall make out duplicate warrants, reciting the facts, and give them to the sheriff, who shall immediately convey the insane person named and deliver him to the contractor employed to care for insane persons. The contractor shall acknowledge the receipt .of the patient, and the warrants shall be returned, one to the judge or county commis- sioner issuing it, and the other to the secretary of the board of commis- sioners of the insane. When it is represented to the probate judge, upon verified petition of any relative or friend, that any person is insane or mentally incompetent to manage his property, the judge must cause a notice to be given to the 1 Laws of Montana, Eevised Statutes, 1879, pp. 259, 260, 337, 338, 348, 448. 449, 555-559. Laws of Montana, 1883, pp. 112, 113. APPENDIX MONTANA. supposed incompetent person five days, at least, before the hearing, and such person, if able to attend, must be produced before him. If, after a full hearing and examination, it appear to the probate judge that the person in question is incapable of taking care of himself, he shall appoint a guardian, who shall have the care and custody of the person of his ward and the management of his estate. The question of the patient's restoration to sanity may be determined by petition to the probate judge, who shall summon a jury and have the question tried. All persons adjudged insane, whether indigent or not, shall be cared for by the Territory, if so desired, under the contract made by the Gov- ernor of the Territory for the care and maintenance of indigent insane ; and no person so adjudged insane shall be refused admission into any asylum provided by the Territory, nor shall the Territory ask or receive any compensation therefor. If any defendant in a criminal case, upon whom the court is about to pass judgment, declare that he is insane, the court, if it finds there is reasonable cause for believing the declaration, may order a jury to be impanelled, and a trial had. If the jury find that the defendant is insane, the court shall order him to be placed in the custody of the person provided by law for the keeping of insane persons ; if no such person is provided, then to the custody of some suitable person. Whenever it shall appear to the satisfaction of the court that such person has become sane, it shall order him to be produced for judgment. If any defendant, at the time he is arraigned, declares that he is in- sane, or there is reasonable cause for believing him insane, the like proceedings shall be had as in the case of a prisoner about to receive judgment. If the jury find that the defendant is sane, the trial shall proceed ; but if insane, the defendant shall be delivered to the custody of the person provided by law for the keeping of the insane, or to the custody of some suitable person. If the defendant recover his sanity, the trial shall proceed. If, after any criminal is sentenced to death, the sheriff has cause to believe that such criminal has become insane, he may summon a jury of twelve competent jurors, with the concurrence of the judge of the court by which the judgment was rendered, to inquire into such insanity, giving notice thereof to the prosecuting attorney. If it is found by the jury that such criminal is insane, the sheriff shall suspend the execution of the sentence until he receives a warrant from the Governor, or from the supreme or district court, directing the execution of the criminal. The Governor, as soon as he is convinced that the criminal has recovered his sanity, may appoint a time for the execution, or may, in his discre- tion, commute the punishment to imprisonment for life. Whenever it appears that a territorial convict is insane, the warden, or other officer in charge of the penitentiary or prison, shall certify the fact to the probate judge of the county in which the prison or penitentiary is. The judge shall cause the convict to be brought before him, and at the same time and place a jury of three citizens of his county, one of whom shall be a licensed physician. If the jury, after a careful exami- nation, certify that the charge is correct, the judge shall have such insane person delivered over to the contractor for the custody, maintenance, and APPENDIX NEBRASKA. 485 treatment of insane persons. If, before the expiration of said convict's sentence, it appears to the contractor that he is restored to reason, he shall notify the sheriff, and such convict shall be confined in the prison or penitentiary for the remainder of his term. NEBRASKA. 1 In each organized county there shall be a board of commissioners of insanity of three members, who may subpoena witnesses, administer oaths, etc. The clerk of the district court shall be ex officio clerk of the board. The other two members shall be appointed by the judge of the district court, and one of them shall be a respectable practising physician, and the other a respectable practising lawyer. In case of the temporary absence or inability to act of two of the commissioners, the judge of the district court may act in the place of one of the commissioners, or the commissioner present may call to his aid a respectable practising physi- cian or lawyer. The commissioners shall have cognizance of all applica- tions for admission to the hospital, or for the safe keeping otherwise of insane persons in their respective counties, except in cases specially pro- vided for. Applications for commitment shall be made in the nature of an infor- mation alleging that the person is believed by the informant to be insane and a fit subject for treatment in the hospital, and must state that such person is found in the county, and give what is known in regard to his settlement. The commissioners shall at once investigate the case, and may require the alleged insane person to be brought before them, and kept in suitable custody until their investigation is concluded ; but they may dispense with this, if they think it will be injurious to such person, or for any reason deem it unnecessary. They shall hear the testimony offered for and against the application, and in each case shall appoint some regular practising physician of the county, who may, or may not, be of their own number, to see the alleged insane person, and make a personal examination. This physician shall make a certificate, stating whether or not he finds the person insane, and, in connection with his examination, he shall endeavor to obtain from the relatives of the insane person, or from others, correct answers to certain prescribed questions touching the history and condition of the patient. The questions and answers shall be attached to his certificate. On the return of this certi- ficate, the commissioners shall find whether the person alleged to be insane is insane, and Avhether he is a fit subject for treatment in the hospital. They shall also state what is ascertained about his settlement. If the person is found insane, they shall issue a warrant authorizing the 1 Compiled Statutes of Nebraska, Guy A. Brown, 1881, pp. 292, 300-309, 732,747. 486 APPENDIX NEBRASKA. superintendent of the hospital to receive and keep such person as a patient. The sheriff shall then deliver the patient, with the physician's certificate and the order of the court, to the superintendent of the hos- pital. If the sheriff is not at hand, the commissioners may appoint some other suitable person to execute the warrant ; but no female shall be taken to the hospital without the attendance of some other female or some rela- tive. Any relative or friend of the patient, who is a suitable person, shall have the privilege, if he so request, of executing the warrant, but shall receive no fees for so doing. The warrant endorsed by the super- intendent, acknowledging the receipt of the patient, shall be returned to the clerk of the commissioners. If a patient has a legal settlement in any county, his expenses shall be paid by that county. If he has no legal settlement, his expenses shall be paid by the State. All patients shall be on an equal footing in the hospital, except that if the relatives or immediate friends of any patient shall desire it, and shall pay the expense thereof, a patient may have special care. The relatives or friends of any patient in the hospital shall have the privilege of paying any portion, or the whole, of the expenses of such patient. If the hospital is full, or if for any reason the patient cannot be received and it is not safe that he be allowed to go at liberty, the com- missioners shall require that such patient be suitably provided for otherwise, until such admission can be had. Such patients shall be cared for either as public or as private patients. Those shall be treated as private patients whose relations or friends will agree to provide for them without public charge. The commissioners shall appoint some suitable person as special custodian to restrain and care for such patients in such way as best to secure their comfort and safety and the safety of others. In the case of public patients, the commissioners shall require that they be restrained and cared for by the commissioners of the county or over- seers of the poor at the expense of the county. If there is no poor-house for the reception of such patients, or if no more suitable place can be found, they may be confined in the jail of the county in charge of the sheriff. Where persons are alleged to be insane, but it is not desired to send them to the hospital, the commissioners of the insane, on application, may make examination, and, on proof of their insanity and need of care, may make provision for their restraint and care within the county, either as public or private patients. Insane persons who have been under care outside of the hospital by authority of the commissioners of the insane of any county may, on application, be transferred by the commissioners to the hospital, when- ever they can be admitted thereto. If the admission is within six months after the inquest already had, another inquest shall not be necessary, unless the commissioners deem it advisable. If it becomes necessary, for want of room in the hospital, to discrimi- nate in the general reception of patients, a selection shall be made as fol- lows : (1) Recent cases (of less than one year's duration). (2) Chronic cases (of more than a year's standing, but with favorable prospects of recovery). (3) Cases which have been longest on file. (4) The indigent have a preference, other things being equal. APPENDIX NEBRASKA. 487 Any patient who is cured shall be immediately discharged by the superintendent. Upon such discharge, the patient, if not otherwise supplied, shall be provided by the superintendent with suitable clothing and a sum of money not exceeding $20. If a patient proves incurable and is not dangerous to be at large, his relatives, with the consent of the board of trustees, may remove and take charge of him. If a patient in the hospital is not cured and is dangerous to be at large, the commissioners of insanity of the county where he belongs, on making provision for the care of such patient within the county, may authorize his discharge, if the relatives or immediate friends request it. The board of trustees, or, in the interim between the meetings of the board, the superintendent with two trustees, may order the discharge or removal of incurable and harmless patients, whenever it is necessary to make room for recent cases. If patients so discharged need further care, the commissioners of insanity shall be notified, and shall at once provide for their care in the county. If it is alleged that a person confined as a patient in the hospital is not insane, and is unlawfully detained, a judge of the district court of the county in which the hospital is situated, or of the county where the person detained belongs, shall appoint a commission of not more than three persons, one of them a physician, and, if two or more are appointed, one a lawyer, and they shall inquire into the merits of the case. They shall have an interview with the patient in such manner as they deem most desirable, shall talk with the officers, and examine the records of the hospital. They shall then make a report to the judge, and shall accompany their report with a statement of the case signed by the superintendent. If the judge shall find the person not insane, he shall order his discharge. Such a commission shall not be repeated ottener than once in six months, in the case of any one patient, nor shall it be appointed within six months of the patient's commitment. The provisions in regard to the support of the insane at public charge are not construed to release the estates of such insane persons, nor their relatives, from liability for their support, but the board of county commis- sioners may release the relatives from a portion, or even the whole of the burden, if they think it reasonable and just to do so. No idiots shall be received or kept in the hospital, and any such there shall be sent to the counties where they belong. If it is shown to the satisfaction of the commissioners of insanity of any county that a person kept as a patient within the county is no longer in need of care, they shall at once order his discharge. Insane persons from other States and Territories may be received on the same footing, and on the same conditions as private pay patients. A person who becomes lunatic or insane after the commission of a crime or misdemeanor, ought not to be tried for the offence during the continuance of the lunacy or insanity. If, after verdict of guilty and before judg- ment pronounced, such person become lunatic or insane, no judgment shall be given while such lunacy or insanity shall continue. If, after judgment and before execution' of the sentence, such person shall become lunatic or insane, then, in case the punishment be capital, the execution 488 APPENDIX NEVADA. thereof shall be stayed until the recovery of said person. In all such cases it shall be the duty of the court to impanel a jury to try the ques- tion whether the accused be, at the time of impanelling, insane or not. In the case of convicts, sentenced to death, who appear to be insane, a judge of the district court shall summon a jury of twelve men to inquire into such insanity, and shall give notice of the time of trial to the district attorney. If the finding shall be that the convict is insane, the judge shall suspend the execution, and notice shall be sent to the Governor. When the Governor becomes satisfied that the convict has recovered his sanity, he may appoint a time for the execution. No person alleged to be insane shall be restrained of his liberty, other- wise than as provided by law, except for the safety of persons or property until the proper authority can be obtained ; and any one abusing or treating an insane person with wanton cruelty or severity, shall be guilty of a misdemeanor, and liable to an action for damages. NEVADA. 1 The judge of the district court in each judicial district, upon the application of any person under oath, setting forth that any person, by reason of insanity, is unsafe to be at large, or is suffering under mental derangement, shall cause the said person to be brought before him at a time appointed, and shall also cause to appear, at the same time, one or more licensed practising physicians, who shall examine the person alleged to be insane. If the physician, after a careful examination, shall certify upon oath that the charge is correct, and if the judge is satisfied that the person, by reason of his insanity, is unfit to be at large, and is incom- petent to provide for his own care and support, and has no property applicable to the purpose, and has no near kindred within the State of sufficient means or ability to care properly for him and his support, he shall cause such indigent insane person to be conveyed to the insane asylum of the State, and placed in charge of the superintendent. Paying patients, whose friends or property can pay their expenses, shall pay according to the terms directed by the board of commissioners; but the insane poor shall in all respects receive the same medical care and treatment from the institution, and no record of debt shall be made against them. When an indictment is called for trial, or, upon conviction, the defen- dant is brought up for judgment, if a doubt shall arise as to his sanity, the court shall order the question to be submitted either to the regular jury, or to a jury specially called to inquire into the fact. The trial of 1 Compiled Laws of Nevada, 1873, Vol. I. pp. 206, 525, 526, 539, 540; Vol. II. pp. 383, 384. Statutes of Nevada, 1879. p. 140; 1881, pp. 59-63; 1883, pp. 102, 103. APPENDIX NEW HAMPSHIRE. 489 the indictment shall be suspended until the question of sanity is deter- mined. The mode of proceedings at the trial is prescribed. If the jury find that the defendant is sane, the trial of the indictment shall proceed, or judgment be pronounced, as the case may be. If he is found insane, the trial or judgment shall be suspended until he becomes sane, and the court, if it deem the prisoner's discharge dangerous to the public, may order that he be committed to the care and custody of some proper per- son, and that upon his becoming sane he be redelivered to the sheriff, who shall place him in proper custody until he be brought to trial or judgment, as the case may be, or be legally discharged. If, after the judgment of death, there be good reason to suppose that the defendant has become insane, the sheriff, with the concurrence of the judge who rendered judgment, may summon a jury of twelve men to inquire into the supposed insanity. The district attorney shall attend the inquisition. If it be found that the defendant is insane, the sheriff shall suspend the execution of the judgment until he receives a warrant from the Governor, who, when the defendant recovers his sanity, may fix a day for the execution. Whenever a convict, while undergoing imprisonment in the Nevada State Prison, shall become insane, and be so adjudged by a commission of lunacy appointed by the court, as in other cases of insanity, it shall be the duty of the warden to deliver such convict to the superintendent of the State Insane Asylum for detention and treatment. If such convict be restored to sanity before the expiration of his sen- tence, the superintendent shall deliver him to the warden of the prison, to be retained therein for the unexpired term of his sentence, unless said convict shall be released by order of the board of pardons. NEW HAMPSHIRE. 1 If any insane person is in such condition as to render it dangerous that he should be at large, the judge of probate, upon petition of any person, and such notice to the selectmen of the town in which such insane person is, or to his guardian, or to any other person as he may order all which may be done as well in vacation as in term time may commit such insane person to the asylum. Any insane pauper supported by any town may be committed to the asylum by order of the overseers of the poor, and there supported at the expense of the person, town, or county chargeable with his support. If the overseers neglect to make such order in relation to any insane county pauper, the supreme court, or any two judges thereof in vacation, may 1 General Laws of New Hampshire, 1878, pp. 60-63, 595-597. New Hampshire Laws, 1879, p. 389 ; 1881, p. 530. 490 APPENDIX NEW HAMPSHIRE. order such pauper to be committed to the asylum and there supported at the expense of the county. The parent, guardian, or friends of any insane person may cause him to be committed to the asylum, with the consent of the trustees, and there supported on such terms as they may agree upon. No person shall be committed to the Asylum for the Insane, except by the order of the court or the judge of probate, without the certificate of two reputable physicians that such person is insane, given after a personal examination within a week of the committal ; and such certificate shall be accompanied by a certificate from the judge of the supreme court, or court of probate, or mayor, or chairman of the selectmen, testifying to the genuineness of the signatures and the respectability of the signers. Any insane person committed to the asylum by his parent, guardian, or friends, who has no means of support, and no relatives of sufficient ability chargeable therewith, and no settlement in any town, and who is unsafe to be at large, shall be supported by the county from which he was committed. If any insane person is confined in any jail, the supreme court may order him to be committed to the asylum, if they think it expedient. Any insane person committed to the asylum by order of the supreme court, such person having been charged with an offence the punishment whereof, as prescribed by law, is death or confinement in the State Prison, shall be supported at the expense of the State. Any person committed to the asylum may be discharged by any three of the trustees, or by any justice of the supreme court, whenever the cause of commitment ceases, or a further residence at the asylum is not necessary. But any person so discharged, who was under sentence of imprison- ment, which has not expired, shall be remanded to prison. Some of the trustees shall visit the asylum at least twice a month, and shall give the patients an opportunity to see them in private. If, in their opinion, a further residence at the asylum is not necessary for any patient, it shall be their duty to discharge him. Patients are to be furnished with writing materials, and may send letters to the board of trustees, which shall be delivered without inspection. Whenever the grand jury shall omit to find an indictment against any person for the reason of insanity or mental derangement, or any person prosecuted for an offence shall be acquitted by the petit jury for the same reason, the court, if they are of opinion that it will be dangerous to the people that such person should go at large, may commit him to the prison, or to the Asylum for the Insane, there to remain until he is dis- charged by due course of law. The Governor and Council, or the supreme court, may discharge any such person from prison or transfer any prisoner to the Asylum for the Insane, whenever they are satisfied that such discharge or transfer will be conducive to the health and comfort of such person, and to the welfare of the public. In case of the sudden death of any patient in the asylum, a coroner's inquest shall be held. APPENDIX NEW JERSEY. 491 NEW JERSEY. 1 No person shall be committed to an insane asylum, except upon an order of some court or judge authorized to send patients, without lodging with the superintendent (1) a request, signed by the applicant, giving the name, residence, and various other facts regarding the patient, and (2) a certificate, dated within one month, signed by a respectable physi- cian, certifying the patient's insanity. Each person signing the request or certificate must give his residence and occupation. Each county shall be entitled to send its just proportion of patients. Whenever any pauper in a county entitled to send patients to the asylum may be insane, it shall be the duty of the overseers of the poor in the township where he resides to apply to a judge of the court of common pleas of the county. The judge shall call one respectable physician, and make an investigation, and, if satisfied that the disease is of such a nature as may be cured, he shall make a provisional order that the pauper be taken to the asylum, and kept until restored, if this be effected in three years. Before this order shall take effect, it shall be submitted, with the other papers in the case, to the "chosen freeholders" of the township where such lunatic is found, who, if they are satisfied that the lunatic has a legal settlement in their county, shall endorse their approval upon the order, and it shall then be executed, and the pauper taken to the asylum. Copies of all the papers and proceedings shall be sent to the superinten- dent of the asylum. The case shall also be reported to the board of chosen freeholders, who shall raise the money for the pauper's support in the asylum. When a person who is in indigent circumstances, but not a pauper, becomes insane, application may be made to any judge of the court of common pleas of the county where he resides, and the judge shall call a respectable physician and other witnesses, and, either with or without the verdict of a jury, in his discretion, shall decide the case as to the patient's insanity and indigence. If he find the person insane, and his estate insufficient, he may make a certificate which will entitle the patient to admission to the asylum, and to support there, at the expense of the county, until he is restored to sanity, if effected in three years. If the investigation is made without summoning a jury, the certificate of the judge must be approved by the "freeholders" of the township in the manner above stated in the case of an insane, pauper. When the expenses of an indigent patient in the asylum have been paid by his friends for six months, if the superintendent shall certify that he is a fit patient, and likely to be benefited by remaining in the institu- tion, the "chosen freeholders" of the county of his residence, on appli- cation made, may defray the expenses of his remaining a year, and may 1 Kevision of the Laws of New Jersey, 1709-1877, Yol. I. pp. 601-628; Vol. II. p. 1119. Laws of New Jersey, 1879, p. 176; 1880, pp. 89, 90, 204; 1883, p. 216. 492 APPENDIX NEW JERSEY. repeat the same for two succeeding years, upon like application, and the production of a new certificate from the superintendent each year. No patient is to be admitted for a less period than six months, except in special cases. When there are vacancies in the asylum, the managers may authorize the superintendent to receive paying patients upon the certificate of in- sanity by a regular physician, sworn to before a magistrate and by request of a responsible person, who shall give bonds. Town and county officers, sending a patient to the asylum, shall see that he is provided with suitable clothing. Money paid for the support of an insane person may be collected from his estate or from the persons liable to maintain him. The provisions above stated are not to abridge the power of the court of chancery over the person and property of insane persons. If the judge to whom application is made on behalf of an insane pauper is satisfied by the examination that such pauper, though not curable, can not be provided for by the overseers of the poor of the township, or at the poor-house of the township or county, with comfort, and without danger to himself and others, he shall order the pauper to be removed to the asylum. If the board of chosen freeholders of any county desire and request that a patient be kept in the hospital beyond the period of three years, it may be done, the county continuing to pay the expenses. Any patients, except those under a criminal charge, or liable to be removed to prison, may be discharged by the board of managers upon the superintendent's certificate of a complete recovery; and they may send back to the poor-house of the county or township whence he came any person admitted as "dangerous" who has been two years in the asylum, upon the superintendent's certificate that he is harmless, and will probably continue so, and is not likely to be improved by further treat- ment. When the asylum is full, the managers may order the removal of a patient upon the superintendent's certificate that he is manifestly incur- able, and can probably be rendered comfortable at the poor-house ; and they may also discharge and deliver any patient, except one under a criminal charge, to his relatives or friends, who will undertake with good sureties for his peaceable behavior, custody, and maintenance, without further public charge. No patient shall be discharged without suitable clothing, and money not exceeding $10. If a person is lunatic, and in need of a guardian, a commission of lunacy shall issue out of the court of chancery, and an inquest shall be held. If the lunacy is found, the chancellor shall transmit a copy of all the proceedings to the orphans' court, where a suitable person shall be appointed as guardian, who shall have the care and safe keeping of the lunatic and his property. No lunatic or idiot shall be arrested or held in custody on any civil process, and if such a person is arrested, a writ of habeas corpus may issue. If any lunatic furiously mad or dangerous is found going at large, any two justices of the peace of the county where he is found may direct the overseers of the poor of the city or township to cause him to be appre- APPENDIX NEW JERSEY. 493 bended, and safely locked up and chained, if necessary, in some secure place in the city or township where he has, or had, his last legal settle- ment. If he has no settlement that can be ascertained, he may be conveyed to any place provided in the county for the reception of maniac or lunatic persons, and, if there is no such place, he may be taken to the jail, there to be safely kept until his place of settlement is ascertained, or, failing in that, some order on the subject is made by the court of common pleas. The expenses shall be collected out of the estate of the lunatic, or, if he has no estate, they shall be paid by the township or county, according as he has a settlement or not. These provisions are not intended to abridge the authority of the chan- cellor touching such lunatic, nor to prevent any of the friends or relations of such person taking him under their own protection, so long as they can take care of him. It is the duty of the overseers of the poor of the several townships in each county to make out a list of all the poor lunatics and idiots within their limits, giving all the facts connected with each case. If the board of chosen freeholders of the county think there is reasonable ground for believing that any of such persons can be restored to their right mind, they shall have them taken to the State Lunatic Asylum. When a person shall have escaped indictment, or have been acquitted of a criminal charge or of a misdemeanor upon trial, on the ground of insanity, the court shall carefully inquire whether his insanity in any degree continues, and, if it does, shall order him in safe custody, and to be sent to the asylum. If any person in confinement under indictment, or under any other than civil process, shall appear to be insane, the judge of the circuit court of the county where he is confined shall make an investigation, call a respectable physician and other witnesses, invite the prosecutor of the pleas to aid in the examination, and, if he deem it necessary, call a jury. If it is proved that the person is insane, the judge may discharge him from imprisonment, and order his safe custody and removal to the asylum, where he shall remain until restored to his right mind. Whenever he recovers, he shall be remanded to prison for further criminal proceedings, or be discharged. A criminal lunatic may be discharged by order of one of the. justices of the supreme court if, upon due investigation, it shall appear safe, legal, and right to make such order. If any person confined in the State Prison as a convict shall appear to be insane, the judge of the circuit court of the county in which the prisoner is situated, shall, upon information of the fact from the physi- cian of the prison, institute an inquiry, call two respectable physicians and other witnesses, invite the Attorney-General to aid in the examina- tion, and, if he think it necessary, call a jury. If it is proved that the prisoner is insane, the judge may order his safe custody and removal to the State Lunatic Asylum, to remain at the expense of the State until restored to his right mind ; and then, if his term of imprisonment shall not have expired, he shall be remanded to the prison, to serve out the unexpired portion of his term of imprisonment. 494 APPENDIX NEW MEXICO. Insane persons may be sent to county asylums existing or to be estab- lished, instead of the State Asylum, when it is thought best. The board of managers are required to keep notes of their visits in a bound book kept for the purpose, to be inserted in their annual report to the Governor. NEW MEXICO. 1 (TERRITORY.) If any person is alleged to be a lunatic or habitual drunkard, it shall be lawful for any district judge in the county where the person is or resides, to issue a commission to inquire into the lunacy or habitual drunkenness. No such commission shall issue except upon a petition in writing of a relation by blood or marriage of the person therein named, or of a person interested in the estate. The commission may issue to one person only, or to two or more. The judge shall make an order that notice be given to the alleged lunatic or habitual drunkard, or to some of his near relatives or friends. The commissioner or commissioners may direct the sheriff to summon six or twelve persons upon the inquest, as the case may seem to require. If the alleged lunatic or habitual drunkard is without property, to pay expenses, the judge in person may hold said commission during the term of the court, and have an inquest impanelled from the jurors attending the court. Every person aggrieved by any inquisition may traverse the same upon, or after, its return, and proceed to trial thereon before a jury. Notwith- standing any traverse that may be pending, the court may make such order as seems necessary for the care and custody of the person and the management of his estate. If the person is found a lunatic or habitual drunkard, it shall be lawful for the court to commit the custody and care of the person or estate, or both, of such lunatic to such person or persons as they shall deem most suitable. This committee shall give security, and shall have the management and control of the person and estate of the lunatic. A committee of the person may be appointed separately from the committee of the estate. No person found by inquisition to be a lunatic or habitual drunkard, shall be arrested on civil process ; and, if arrested, he shall be discharged by the court. If in any civil action any person arrested shall appear to be of unsound mind, the jailer or keeper shall give notice of the fact to two justices of the peace, who shall, within five days, attend at the prison and make an examination, and, if they find the person to be a lunatic, shall certify the same to the clerk of the district court. The court, or a judge thereof in 1 General Laws of New Mexico, L. B; Prince, 1880, pp. 380-389. APPENDIX NEW YORK. 495 vacation, shall appoint a day for a hearing, and publish notice, and inform the creditor a week at least before the hearing, that application has been made for the discharge of the prisoner. If the court or judge, on the hearing, find the prisoner of unsound mind, an order shall be made for his discharge, provided that, if it appears that the person is not fit to be set at large, the court or judge shall make an order that he be detained in custody, or delivered to his kindred or friends, who shall be responsible for his safe keeping, and who shall restrain him from the commission of any offence. Whenever it shall appear, upon the trial of any person charged with a crime or misdemeanor, that such person was insane at the time of the commission of the same, and he shall be acquitted by the jury on that ground, the court shall have power to order such person to be kept in strict custody, in such place and in such manner as to the court seems fit, so long as such person continues to be of unsound mind. The same proceedings shall be had if any person indicted for an offence shall, upon arraignment, be found to be a lunatic by a jury impanelled for the purpose ;' or if, upon the trial of any person indicted, he appears to the jury to be then a lunatic, the court shall have him put in the care and custody of some suitable person. If a person found by inquisition to be a lunatic or habitual drunkard has not, and if his friends have not, money for his support, he shall be kept at the expense of the county. NEW YORK. 1 No person shall be committed to, or confined as a patient in, any asylum or institution, public or private, except upon the certificate of two physicians under oath setting forth the insanity. The physicians must be of reputable character, graduates of some incorporated medical college, permanent residents of the State, and have been in practice three years. No certificate shall be made except after a personal examination, and in a form prescribed by the lunacy commissioner. It must be in the prescribed form and bear date not more than ten days prior to the com- mitment. The physicians must not be in any way connected with the asylum to which the insane person is committed. The patient shall not be kept in the asylum more than five days unless before or within that time the certificate is approved by a judge or justice of a court of record of the county or district in which the alleged lunatic resides, and the judge or justice before approving the certificate may in- 1 Kevised Statutes of New York, Banks & Brothers, 7th ed. Vol. III. pp. 1887, 1888, 1890, 1899-1933, 2568, 2590, 2649, 2653; Vol. IV., The Code of Civil Pro- cedure, pp. 318, 464-468; Code of Criminal Procedure, pp. 12, 69, 88, 93, 96, 97, 126, 127, 175; Penal Code, pp. 5, 47, 79, 93. Laws of New York, 1882, Vol. 2. pp. 109, 500 ; 1883, p. 199. 496 APPENDIX NEW YORK. stitute inquiry, and, in his discretion, call a jury to determine the question of lunacy. There must be a certificate from some judge of a court of record, stating that the physicians have the requisite qualifications. The superintendent of any institution, public or private, shall, within three days of the commitment of any insane person, make a descriptive record of his case in a book especially provided for that purpose, and keep a record of his condition and treatment, from time to time, including the forms of restraint used. He shall also record the circumstances of the discharge or death of all patients. If a pauper becomes lunatic, the county superintendents of the poor of the county or town where he is chargeable may send him to any State lunatic asylum by an order under their hands. In case the committee or guardian of any lunatic, or his relatives, neglect to confine or maintain him, or are not of sufficient ability to do so, the overseers of the poor or constable of the city or town where any such lunatic shall be found, shall report the same forthwith to the super- intendent of the poor, who shall apply to the county judge, special county judge, or surrogate, who, being satisfied that it is dangerous for such lunatic to go at large, shall order him to be apprehended and properly confined, and within ten days taken to some State lunatic asylum, or to such other asylum as may be approved by a standing order of the super- visor of the county. If any person, not a pauper but in indigent circumstances, becomes insane, application may be made to any county judge, special county judge, judge of a superior court or common pleas of the county where he resides, and the judge shall investigate the facts in the case, both as to indigence and as to insanity. If the judge finds that there is reasonable cause, he shall fix a time and place for a hearing, and give notice to one of the superintendents of the poor of the county chargeable with the ex- pense of supporting such person in the asylum, and shall then proceed to ascertain when such person became insane. The judge may require the friends of the patient to give security to remove him from the asylum as soon as he shall recover. If such patient has not recovered at the end of two years, the managers of the asylum may cause him to be returned to the county from which he came. The judge shall file all the papers in the case, together with his decision, with the clerk of the county, and report the facts to the supervisors, who shall provide the money for the support of such indigent lunatic. If the expenses in the asylum of an indigent insane patient, not a pauper, have been paid by his friends for six months, and the superin- tendent shall certify that he is a fit patient and likely to improve, the supervisors of the county of his residence are required, upon a sworn ap- plication, to defray his expenses for remaining another year. And they shall repeat the same for two years more, upon like application, and the production of a new certificate from the superintendent. If any lunatic, or friend on his behalf, is dissatisfied with any final decision of a county judge, special county judge, surrogate, judge of the superior court or court of common pleas, of a city or police magistrate, in committing to an asylum, he may, within three days after such order, appeal to a justice of the supreme court, who shall thereupon stay all proceedings, and APPENDIX NEW YORK. 497 forthwith call a jury to decide upon the fact of lunacy. If, after a fail- investigation, aided by the testimony of at least two respectable physi- cians, the jury find the person insane, the justice shall confirm the order for his being sent immediately to an asylum. If any of the judges above mentioned refuse to make an order for the confinement of a dangerous insane person, they shall state their reasons in writing, so that any person aggrieved may appeal to a justice of the supreme court, who shall determine the matter in a summary way, or call a jury at his discretion. No person committed to any prison, jail, or house of correction, as a dangerous lunatic, shall be kept there longer than ten days ; if, at the end of that time, he continues to be insane, he shall be sent forthwith to some State lunatic asylum, or some other approved asylum. If a person found to be a lunatic, or his committee, is not possessed of sufficient property to maintain himself, his father, mother, or children, if they are of sufficient ability, shall be compelled to provide for and maintain him. If such relatives have not sufficient means, then the superintendent of the poor of the county shall send such pauper lunatic to a State asylum, or to such private asylum as may be approved by a standing order of the supervisors. Whenever any person, who is possessed of sufficient property to maintain himself, becomes, by lunacy or otherwise, so far disordered in his senses as to be dangerous, it shall be the duty of the committee of his person and estate to provide a suitable place for his confinement, and to confine and maintain him in such manner as shall be approved by the proper legal authority ; and in every succeeding attack of lunacy he shall be sent, within ten days, to some State lunatic asylum, or to such public or private asylum as may be approved by a standing order of the supervisors of the county. The superintendents and overseers of the poor are severally enjoined to see that this provision is carried into effect, as well in cases where the lunatic or his relatives are of sufficient ability to defray the expenses as in case of a pauper. The overseers of the poor have authority to compel the relatives, guardian, or committee of the person and estate, as the case may be, to confine and maintain an insane person, at their discretion, and to collect the costs of his confinement. No pauper who has not resided in the State for at least one year next prior to the application shall be committed to any State insane asylum. Any soldier or sailor, an inmate of the New York State Soldiers' and Sailors' Home, who shall be found insane, may be transferred by an order of the president and secretary of the board of trustees and the superintendent of the home to any State lunatic asylum, there to remain at the expense of said Soldiers' Home until discharged. The commissioners of the department of public charities and correction of the city of New York may, in their discretion, transfer any insane person in their custody or control to any State lunatic asylum, the officers of which will consent to receive the same. The expense of maintenance shall be paid by said commissioners. It shall be the duty of all captains, owners, agents, and consignees of all ships or vessels arriving at the port of New York, having as a pas- 32 498 APPENDIX- NEW YOKK. senger any lunatic, to keep, provide, and care for such person, on board such ship or vessel, until such person shall have been delivered over and placed under the care of the commissioners of emigration. If a person is incompetent to manage himself or his affairs on account of lunacy, application may be made to the court having jurisdiction for the appointment of a committee of the person, or of the property, or of both. The court, if the case seems a proper one, shall make an order, either that a commission issue for the purpose of inquiring into the case, or that the question be submitted to a jury at a term of the court. If the person is found to be incompetent, the court makes such order as justice requires. The committee appointed, either of the person or of the property, must give security before entering upon his duties. If any inmate of any State almshouse, when admitted, is insane, or thereafter becomes insane, and the accommodations in the almshouse are not adequate and proper for his treatment, the secretary of the State Board of Charities may cause his removal to the appropriate State asylum for the insane. A competent physician shall be appointed by the Governor with the consent of the Senate, who shall be designated the State commissioner in lunacy. It shall be his duty to visit and examine all the asylums, public and private, and report annually to the legislature. If he has reason to believe that any person is unlawfully confined or improperly treated, or that there is any general mismanagement, he shall make an investigation ; and he is empowered to summon witnesses, administer oaths, and issue orders such as the case may require. He shall notify the district attorney, who shall be present at all his investigations into matters of general administration and management, to examine witnesses in behalf of the people. The commissioner in lunacy shall exercise the powers belonging to referees appointed by the supreme court, and he may direct the authorities of the asylum, where affairs have been investi- gated, to correct any rule or abuses as he thinks best. It is also the duty of the lunacy commissioner to grant licenses for private asylums ; and any person establishing a private insane asylum without such license is guilty of a misdemeanor. If his orders are dis- obeyed, the case shall be laid before the supreme court and be by it de- cided and disposed of. A person is not excused from criminal liability, as a lunatic or insane person, except upon proof that at the time of committing the alleged criminal act he was laboring under such a defect of reason as either not to know the nature and quality of the act he was doing, or not to know that the act was wrong. If any person in confinement, under indictment for the crime of arson, murder, or attempt at murder, or highway robbery, shall appear to be insane, the court of oyer and terminer in which the indictment is pend- ing may, with the concurrence of the presiding judge of such court, summarily inquire into the sanity of such person, and may, for that purpose, appoint a commission to inquire into the facts of the case, and report to the court ; and if the court find such person insane, or not of sufficient capacity to undertake his defence, they may remand him to such State lunatic asylum as in their judgment is meet, there to remain until APPENDIX NEW YORK. 499 restored to his right mind, when he shall be returned to prison for further criminal proceedings, unless he be otherwise discharged, according to law. If any person is confined under conviction for an offence for which the punishment is death, the Governor may inquire into the case, appoint a commission, and, if the convict is found insane and irresponsible, may order his removal to the State Asylum for Insane Criminals, there to remain until restored to his right mind. The medical superintendent of the asylum, whenever he thinks the convict is cured of his insanity, shall report the fact to the State commissioner in lunacy and to a justice of the supreme court of the district where the asylum is situated. If, on inquiry, they are satisfied of his recovery, they shall cause the convict to be re- turned to the sheriff, to be dealt with according to law. Any person charged with arson, murder, or attempt at murder, or highway robbery, and confined in either of the State lunatic asylums as insane, may, upon the application of any superintendent of an asylum, be brought before a justice of the supreme court, who may order his removal to the Asylum for Insane Criminals at Auburn ; and convicts confined in any penitentiary, if insane, may be removed there, to stay until recovered or legally discharged. If any person in confinement under any other than civil process appears to be insane, the county judge of the county where he is confined shall institute an investigation, call two physicians and other witnesses, invite the district attorney to aid in the examination, and, if he deem it neces- sary, call a jury. If the person is found to be insane, the judge may order his removal to a State asylum, to remain until restored. Whenever he recovers, he may be remanded to prison for further criminal proceed- ings, or, if the period of his imprisonment has expired, he may be discharged. The like proceedings may be had in case of an insane person imprisoned on civil process ; but notice shall be sent to the plaintiff in the case, or to his attorney. The defence of insanity must be pleaded in a criminal case at the time the prisoner is arraigned. If a defendant is acquitted on the ground of insanity, the court, if they deem his discharge dangerous to the public peace or safety, must order him to be committed to the State Lunatic Asylum until he becomes sane. When a defendant pleads insanity, the court may appoint a commission, of not more than three persons, to examine the accused, and report to the court as to his sanity at the time the crime was perpetrated. The com- mission must be attended by the district attorney, and the counsel for the defendant may take part in the proceedings. If the commission find the defendant insane, the trial must be suspended until he becomes sane; and the court, if it deem his discharge dangerous, must order that he be com- mitted to a State lunatic asylum, to remain until cured. When he becomes sane, he must be taken from the asylum, and put in proper custody until he is brought to trial. If a defendant in confinement under indictment at any time, before or after conviction, appears to be insane, the court, unless the defendant is under sentence of death, may in a like manner appoint a commission and the like proceedings shall be had. If, after a defendant has been sentenced to death, there is reasonable 500 APPENDIX NW YORK. ground to believe he has become insane, the sheriff, with the concurrence of a justice of the supreme court or the county judge of the county, must impanel a jury of twelve persons to examine the question of the sanity of the defendant. Notice of the trial must be given to the district attorney, and he must attend. If it be found by the inquisition that the defendant is insane, the sheriff must suspend the execution until he is directed by the Governor to proceed. The Governor shall give directions for the disposition and custody of the defendant, and, as soon as he is satisfied of his restoration to sanity, must direct his execution, pursuant to his sentence, unless the sentence is commuted or the convict pardoned. No insane person confined in any county poor-house or county asylum shall be discharged by the keeper, or by the superintendent of the poor, or by any other county authority, without an order from a county judge or judge of the supreme court, founded upon evidence that it is safe, legal, and right to make such discharge. In New York and Kings Counties, however, it shall be sufficient if there is a certificate in writing of the physician of the asylum stating that the discharge is safe and proper. It is provided, in regard to the Utica Asylum, that no patient shall be committed for a shorter period than six months except in special cases. Whenever there are vacancies, paying patients may be committed under special agreement, in conformity with the law regarding commitments, if the cases are recent and promise speedy recovery, or when admission is sought under peculiarly afflicting circumstances. The managers, upon the superintendent's certificate of complete recovery, may discharge any patient except one under a criminal charge liable to be remanded to prison. They may discharge any patient com- mitted as "dangerous," or any patient sent by the superintendent or overseers of the poor, or by the judge of a county, if the superintendent certifies that the patient is harmless and will probably continue so, and is not likely to be improved by further treatment. If the asylum is full, they may discharge patients manifestly incurable that can probably be rendered comfortable in the poor-house, and give preference, in the admitting of patients, to recent cases or those of not over one year's duration. They may discharge and deliver any patient except one under criminal charge, to his relatives or friends, who will give a bond approved by the county judge for the patient's peaceable behavior, safe custody, and comfortable maintenance without further public charge. A criminal lunatic may be discharged by order of one of the justices of the supreme court or a circuit judge, when it appears safe, legal, and right to make such order. No patient shall be discharged without proper clothing and money not exceeding $20 to pay his expenses. Insane female convicts at Sing Sing may be removed to the asylum for insane criminals at Auburn, to stay until restored to reason, and then be returned. Whenever any convict in this asylum for insane criminals shall continue to be insane at the expiration of the term for which he was sentenced, the board of inspectors, upon the superintendent's certificate that he is harmless and is not likely to be improved by further treatment, or upon a certificate that he is incurable and can be made comfortable in the county almshouse, may cause such insane convict to be removed to the county where he was convicted or where he belongs and placed under APPENDIX NORTH CAROLINA. 501 the care of the superintendents of the poor of such county. Or they may deliver such convict, on the expiration of his sentence, to his friends, if they will give security for his safe custody and comfortable maintenance without public charge. If the insanity continues after the expiration of the convict's sentence, he shall be kept in the asylum until adjudged a fit subject to be discharged. If any convict confined in said asylum as a lunatic is restored to reason and is ready to be sent back to prison, he shall be sent to the Auburn State Prison, even though originally sen- tenced to some other prison, but any convict received from a penitentiary shall be returned to the same. The chronic pauper insane from the poor-houses of the counties shall be sent to the Willard Asylum by the county superintendents of the poor, except from those counties having asylums for the insane to which they are authorized to send insane paupers by special legislative enact- ment, or those counties exempted by the State Board of Charities. And all the chronic insane paupers who may be discharged not recovered from the State lunatic asylums, and who continue a public charge, shall be sent to the Willard Asylum and paid for by the counties from which they are sent. The chronic pauper insane from such counties, and in such numbers as may be designated by the State Board of Charities, shall be sent to the Binghamton Asylum. Any of the patients who are recovered or become harmless, may be discharged by the trustees into the care of their friends. The trustees may also deliver any patient who has not recovered to his friends, on their giving proper security for his custody and main- tenance. Harmless patients may also be sent back from this asylum to the counties from which they came, and placed in the care of the super- intendents of the poor. Town or county officials, in committing insane persons, are required to send them well provided with clothing and in a cleanly condition. Any person found guilty of confining a lunatic in any other manner or in any other place than is prescribed by law, is liable to a fine not exceeding $250, or imprisonment not over one year, or both, at the dis- cretion of the court. The terms lunatic and insane include all persons deranged or of unsound mind except idiots. NORTH CAROLINA. 1 For commitment to any insane asylum, some respectable citizen, re- siding in the county of the alleged insane person, shall file with a justice of the peace of the county an affidavit, in prescribed form, stating that he has examined the alleged lunatic, and believes him to be insane, and a fit subject for the asylum. The justice of the peace shall have the supposed 1 Laws of North Carolina, 1883, pp. 237-251. 581, 621. 502 APPENDIX NORTH CAROLINA. insane person brought before him, and shall call to his assistance one or more justices of said county, and they together shall proceed to examine into the condition of mind of the alleged insane person. They shall take the testimony of at least one respectable physician, and such others as they may think proper. If any two of the justices decide that the person is insane, and no friend is found who will become bound with good security to restrain and take care of him until he recovers, the justices shall direct that such insane person be removed to the proper asylum as a patient. The justices shall make a full report of their proceedings to the clerk of the superior court of their county. Whenever an insane person shall be conveyed to any asylum, and the superintendent is in doubt as to the propriety of his commitment, he may convene any three of the directors, who shall examine the matter. If a majority of the three so decide, the patient shall be admitted, but three directors may at any time deliver the patient to any friend who will become bound with good surety to restrain and take care of him. Any three of the board of directors of any asylum, upon the superin- tendent certifying the facts, may discharge or remove any person admitted as insane, when such patient has become of sound mind, or when he is incurable, but not dangerous ; or the said directors may permit a patient to go to the county of his settlement on probation if the superintendent thinks it advisable. If an indigent patient is discharged or removed, except as being recov- ered, it shall be the duty of the sheriff to take him to his county. If an indigent person is discharged recovered, he shall be furnished with money to pay his expenses of travel to the county of his settlement. All bonds for the safe keeping of insane persons shall be in prescribed form, payable to the State of North Carolina, and shall be in the sum of $500. Costs and expenses incurred in regard to a patient shall be paid by the county, unless the patient or those liable for his support have means to pay. If a patient entrusted to a friend is not cared for according to the terms of the bond, any two justices of the peace of the county may send the patient to the proper asylum, unless some other responsible and discreet friend will undertake to take charge of him. The board of public charities shall visit the asylum from time to time, and make reports to the General Assembly. If a person found to be insane has ample means to care for his family and himself, and is capable of declaring his preference to be placed in some asylum outside the State, or if his guardian declares such prefer- ence, and two respectable physicians who have examined him, with the justices who made the examination, deem it proper, the said justices and physicians may recommend that he be placed in the asylum so chosen. The justices shall report the proceedings to the clerk of the superior court of the county. The clerk shall lay the matter before the judge of the superior court of the district where the insane person resides, and, if he approves, he shall so declare in writing, which shall be recorded by the clerk. The said judge shall appoint some friend of the patient to remove him to the asylum designated, and a certified copy of the proceedings APPENDIX OHIO. 503 shall be a sufficient warrant to authorize such friend to act in the matter of his removal. In the commitment of patients to the asylums, priority shall be given to the indigent ; but the boards of directors may also consider the cura- bility of patients. If there is sufficient room, paying patients may be received. If a person found insane cannot be at once committed to an asylum, and he is dangerous to be at large, and cannot otherwise be properly restrained, he may be temporarily committed to the county jail. When a patient kept in the county jail is fit to be discharged, it shall be the duty of the board of county commissioners, on the presentment of a certificate of two respectable physicians, and of the chairman of their board stating the fact, to make an order for his discharge. The judges of the superior court, in their respective districts, shall commit to the proper asylum, if there be room therein, as a patient, any person who may be confined in jail, on a criminal charge of any kind, or upon a peace warrant, whenever the judge shall be satisfied, by the ver- dict of a jury of inquisition, that the alleged criminal act was committed while such person was insane, and that such insanity continues ; and also any person acquitted upon a criminal charge where, on the trial of such person, insanity was relied upon as a defence ; provided, the fact of in- sanity was found as a distinct issue to exist at the time of such trial, or is so found by a jury of inquisition, as such judge may direct. OHIO. 1 Each county is entitled to send patients to the State asylums in pro- portion to its population. No person is entitled to admission unless he has lived in the State one year next preceding the date of his application and his insanity appeared while he resided in the State. The medical superintendent of each asylum shall inform the probate judges of the different counties in his district, each month, of the number of patients to which each county is entitled, and of the number in the asylum from each county. If the quota is not full, the probate judge may, at any time, send an acute case conformably to the laws. Patients may be transferred from one asylum to another upon the order of the Governor, and the recommendation of the medical superintendents of the asylums affected. Patients in the asylums shall be maintained at the expense of the State. For the commitment of patients to asylums, some resident citizen of the proper county shall file with the probate judge of the county an affidavit, stating that he believes the person in question to be insane, or 1 Kevised Statutes of Ohio, 1880. Second Edition, Kevised, Vol. I. pp. 204, 329- 339, 384; Vol. II. pp. 1505-1509, 1688, 1701, 1702, 1720, 1730, 1736, 1831. Laws of Ohio, 1881, pp. 02, 102; 1883, pp. 103, 104, 181, 182. 504 APPENDIX OHIO. unfit to be at large, on account of insanity, and giving the place of his legal settlement. The judge shall order the alleged insane person to be brought before him on a day named, which shall be not later than five days after the filing of the affidavit. He shall summon witnesses, one of whom shall be a respectable physician, and, if the insanity is disputed, he shall summon such witnesses as the parties opposing desire. If the alleged insane person is not in a fit condition to be brought into court, the judge shall visit him personally, and certify that he has ascertained the condition of the person by actual inspection, and the proceedings shall go on in the absence of such insane person. If the judge, after hearing the testimony, is satisfied that the person is insane, he shall cause a certificate to be made by the medical witness, which shall set forth information on twenty-one prescribed points covering the history and con- dition of the patient ; he shall then apply to the superintendent of the asylum in the proper district, transmitting copies of the physician's cer- tificate and his own finding in the case. If the patient can be received, the superintendent shall notify the probate judge, and he shall issue his warrant to the sheriff, or some suitable person or persons, to take the patient to the asylum. The relatives of the patient shall have the right, if they desire it, to convey the patient to the asylum. The receipt of the patient shall be endorsed on the warrant, which shall be returned to the probate judge and filed with the papers in the case. Before the probate judge applies for the commitment of the patient, the medical witness must make a certificate that the patient is free from all infectious diseases and from vermin. The relatives of any person charged with insanity, or who is found to be insane, shall in all cases have the right to take charge of and keep him ; and, in such case, the probate judge who holds the inquest shall deliver the insane person to such relatives. When a patient is sent to the asylum, the probate judge shall see that he has the proper amount of clothing. If the patient cannot be admitted to the asylum, the probate judge shall have the sheriff, or some other suitable person, take charge of him, until such time as he can be received, and, if necessary, the judge may direct the confinement of the patient in the county infirmary or jail, but in a room separate from the criminals. The judge shall see that things necessary are furnished, and, if there is no physician regularly employed to attend the jail or infirmary, he may employ one to attend the lunatic. If an insane person not entitled to admission to the asylum is at large and dangerous, the probate judge may order him to be confined, and provided for, either by some suitable person, or in the jail or infirmary, as above stated. When the attending physician certifies that such person is restored to reason, or that it is no longer necessary to confine him, or if his friends agree to take care of him, the probate judge shall order his discharge. Immediately after the removal, death, escape, or discharge of any patient, or return of an escaped patient, the superintendent shall notify the probate judge of his county ; and he shall also, in case of death, notify one or more of the relatives of the deceased patient. Incurable and harmless patients may be discharged by the superinten- dent and one trustee when it is necessary to make room for a recent case APPENDIX OHIO. 505 from the same county. The superintendent shall notify the probate judge, who shall by his warrant order the removal of the patient to the township of which he is an inhabitant. When a patient is discharged as cured, the superintendent may furnish him with suitable clothing and money not exceeding $20. If a patient discharged as cured becomes a second time insane, the facts shall be set forth in an affidavit by a respectable physician, and the probate judge shall make application to the superintendent of the proper asylum for his commitment. The same proceedings shall then be had as in case of a person found insane upon inquest held for the purpose, as above stated. In the admission of patients, selection shall be made as follows : (1) Recent cases (of less than a year's duration). (2) Chronic cases present- ing the most favorable prospect of recovery. (3) Those for whom appli- cations have been longest on file, other things being equal. (4) No county shall have more than its due proportion of patients, unless there is some other county in the district without patients enough to fill its quota. If the friends of a patient ask for his discharge from the asylum, the superintendent may require a bond for the safe keeping of such patient ; but no patient charged with, or convicted of, homicide, shall be discharged without the consent of both the superintendent and the board of trustees of such asylum. The commissioners of every county in which there now is, or may here- after be established, a county infirmary, shall provide separate apartments for the safe keeping and treatment of lunatics and idiots who have not been, and cannot be, received into either of the lunatic asylums, or who have been discharged therefrom. The directors of the infirmary shall provide for the safe keeping, support, and treatment of patients who are a charge upon the county, and for the treatment and care of such lunatics in their county as may be admitted as pay patients, under regulations made by the directors. When rooms are provided in the county infirmary, insane persons in the county jail shall be transferred to such infirmary. The directors of the Ohio Penitentiary shall provide a suitable depart- ment for the reception of lunatic or insane convicts, to accommodate the convicts that become insane therein. If at any time before the indictment of a person confined in jail charged with an offence, notice in writing be given by any citizen to the sheriff or jailer that such person was insane or an idiot at the time the offence was committed, or has since become insane, the sheriff or jailer shall forthwith notify the probate judge, clerk, and prosecuting Attorney of the proper county, and an examining court shall be held ; and if the judge find that such person was an idiot when he committed the offence, or was then and still is insane, or afterwards became and still is insane, he shall, at his discretion, proceed as [in the case of a person found insane by inquest held. When such lunatic is restored to reason, the prosecuting attorney shall have him recommitted to the jail to answer the offence charged against him. If the prosecuting attorney fails to do this, the superintendent of the asylum or infirmary shall discharge such patient. 506 APPENDIX OHIO. When a person is under indictment, or held for trial or sentence, and it is suggested to the court that the person is not then sane, and the certifi- cate of a respectable physician to the same effect is presented to the court, proceedings shall be had to try his sanity, and the question may be sub- mitted to a special jury. If the person is found insane, the probate judge shall be notified, and shall deal with him as an insane person found so by inquest, and upon recovery he shall be brought to trial or sentence. If the patient is discharged into the care of his friends, the bond given for his support and safe keeping shall contain a condition that he shall, when restored to reason, answer to the offence charged in the indictment, or of which he has been convicted, at the next term of the court thereafter. When a person tried upon an indictment is acquitted on the sole ground that he was insane, that fact shall be certified by the clerk to the probate judge, and the defendant shall not be discharged, but shall be proceeded against as insane, and the verdict shall be prima facie evidence of in- sanity. When a convict in the penitentiary becomes insane, the warden shall give notice to the physician for the prison and the superintendent of the Columbus Asylum for the Insane, who shall examine the convict, and, if they find him insane, shall certify the fact to the warden, who shall forth- with put the insane convict in the department prepared for that purpose. Such insane convicts shall be treated by the physician and by the superintendent of said asylum, and when they are restored, or it is safe for them to work, they shall again be put at hard labor, according to their sentence. If a convict is insane at the expiration of his term of imprison- ment, the probate judge of the county from which he was sent shall take him in charge, and order him to be confined, or otherwise disposed of and provided for, as directed by law. If a convict, at any time before the full execution of his sentence, be represented to the Governor of the State to be insane, the Governor shall inquire into the facts. If he thinks it proper, he may pardon the convict, or commute the sentence, or suspend its execution for a definite time, or from time to time. He may order the convict to be confined in the penitentiary, or a jail, or conveyed to an asylum for the insane for treat- ment. If the sentence is suspended, and the convict recover his reason, the sentence shall then be fully executed. If a convict sentenced to death appears to be insane, the sheriff shall give notice to a judge of the court of common pleas of the judicial dis- trict, and shall summon a jury of twelve men. The judge, clerk, and prosecuting attorney shall attend the inquiry, and, if it be found that the convict is insane, the judge shall suspend the execution. The Governor shall be notified of the finding, and may, as soon as he is convinced that the convict has recovered, issue a warrant directing his execution. APPENDIX OREGON. 507 OREGON. 1 The insane have been kept under the care of a contractor, the State paying a certain sum per week for the board of each patient. The county judge, upon application of any two householders in his county in writing, under oath, setting forth that any person by reason of insanity is suffering from neglect, or is unsafe to be at large, shall cause such insane person to be brought before him, and shall cause to appear, at the same time and place, two or more competent physicians, and the prosecuting attorney of the district, or his deputy, or, in the event of his absence, some practising attorney to represent the State. If the physi- cians, after careful examination, shall certify on oath that the person is insane or idiotic, and the county judge shall find, on the certificate and the testimony produced, that the person is insane or idiotic, he shall cause the insane person to be conveyed to, and placed in charge of, the party or parties contracting to keep and care for the insane and idiotic of the State. An appeal may be taken from the decision of the county judge in the same manner as is provided for appeal from the judgment of county courts in other cases. The appeal may be taken either by the householders making application, or by some one on behalf of the alleged insane person, or by the prosecuting attorney on behalf of the State. The judge shall make inquiry, and, if he finds that the person found insane has any property, he shall appoint a guardian to take care of the same, and said estate shall be applied to supporting the family of the insane person and to paying the expenses of his commitment and support. All the proceedings shall be recorded in the county court, and, if the patient is adjudged insane, a warrant shall be made reciting the findings of the judge, the causes of the insanity when ascertained, and the name, age, nativity, and present residence of the patient. The county judge shall designate some proper person or persons to take the patient to the asylum. Paying patients shall pay according to the terms made with the contractors. The Governor is required to visit and examine the insane confined by law once every six months. He shall also appoint a physician who shall visit and inspect the institution where they are kept as often as once every month, and oftener if necessary. He shall see that the terms of the contract made with the State are fully carried out. He shall have power to discharge any patient when he considers that he is cured. In case of a disagreement between the physician and the contractor as to the sanity of a patient, the Governor may employ some other physician to consult upon the case. Whenever a patient dies, or is ordered to be discharged by the physician, the Governor and the Secretary of State shall be notified, and no board shall be paid after the date of the patient's death or the order for his discharge. The courts of the State shall have power to commit to the care of the 1 General Laws of Oregon, 1843-1872, pp. 361, 364, 620-623. Laws of Oregon, 1878, pp. 71-77 ; 1880, pp. 49-51 ; 1882, pp. 4-6. 508 APPENDIX PENNSYLVANIA. contractors any person Avho has been charged with an offence punishable with imprisonment or death, who shall have been found to be insane or idiotic, and who continues to be insane or idiotic. If the defence in any criminal case be the insanity of the defendant, and he is found not guilty on that ground, the court must, if it deems his being at large dangerous, order him to be committed to any lunatic asylum authorized by the State to receive and keep such persons until he becomes sane, or is discharged according to law. Whenever any convict confined in the State Prison shall, in the opinion of the physician of the prison, be insane or idiotic, the physician shall make oath to the same before the county judge of the county in which the prison is located. The judge shall summon one or more competent physicians to make an examination, and, if in their opinion the convict is of unsound mind, the judge shall report the case to the Governor, who may, in his discretion, cause the convict to be removed to the place pro- vided for the insane and idiotic. PENNSYLVANIA. 1 The trustees of any asylum for the insane where there are women de- tained may appoint a skilful female physician to have charge of the female patients. The Board of Public Charities shall appoint a committee of five of its members to act as the committee on lunacy. One of this committee shall be a member of the bar, and one a practising physician, and each shall be of at least ten years' standing in his profession. The committee on lunacy shall examine into the condition of the insane throughout the State, and into the management of the hospitals, public and private, and all other places in which the insane are kept for care and treatment or detention, and shall make an annual report. The board, among other things, shall have power, with the consent of the chief justice of the supreme court and of the attorney-general, to make rules and regulations : 1. For the licensing of all asylums and places where more than one patient is kept, excepting jails and such hospitals as may be specially ex- empted from the duty of obtaining a license. 2. For securing the proper treatment of all insane persons wherever kept, and to guard against the improper detention of such persons. 3. For determining the forms to be observed in committing, trans- ferring, and discharging all lunatics except those committed by order of a court of record. 1 Brightly's Pardon's Digest of Laws of Pennsylvania, 1700-1872, Vol. 1, pp. 27, 391, 392. Vol. 2, pp. 969-989. Purdon's Annual Digest, 1873-1878, pp. 1893, 1894. Laws of Pennsylvania, 1879, p. 98; 1881, pp. 83, 84, 173; 1883, pp. 21-30, 92. APPENDIX PENNSYLVANIA. 509 There shall be appointed in each county where there is a house or place for the care or detention of the insane a board of visitors of not less than three persons. Women may be appointed members of these boards. The board of public charities shall make rules to insure to the patients the admission to see them of all proper visitors, being members of their family, friends, agents, or attorneys. No person shall be received as a patient for treatment or for detention into any house or place where more than one insane person is detained, or into any house or place where one or more insane persons are detained for compensation, without a certificate signed by at least two physicians, residents in the commonwealth, who have been in the practice of medicine for at least five years, stating that they have examined separately the person alleged to be insane and believe that he is insane, and that the disease is of a character which requires that the person should be placed in a hospital or other establishment for care and treatment ; that they are not related by blood or marriage to the patient, nor in any way con- nected with the hospital in which it is proposed to place him. This certificate must be made Avithin one week after the examination of the patient, and within two weeks of the time of his admission to the hos- pital. It shall be sworn to before a judge of the county where the ex- amination took place, and the judge shall certify to the genuineness of the signatures, and to the standing and good repute of the signers. The person or persons requesting the admission or detention shall sign a writing stating that the person has been removed, and is to be detained at his or their request under the belief that such detention is necessary and for the benefit of the insane person. There shall also be furnished to the persons in charge of the hospital or house a statement signed by the persons requesting the detention of the patient, giving his name, age, residence, occupation, and a list of his relatives, also the circumstances connected with the patient's insanity, and the names and address of his medical attendants for two years. If, through inadvertence, any of the answers are omitted, and there is no reason to doubt the good faith of the parties, the patient may be received and kept, if within seven days the statements are made complete. The regular medical attendant of the house shall, within twenty-four hours after the reception of any patient, examine him, and in case he is of opinion that a detention is not necessary for the benefit of the patient, he shall notify the person or persons at whose instance the patient is detained, and unless within seven days satisfactory proof is exhibited of such necessity the patient shall be discharged and restored to his family or friends. At the time of such examination the medical attendant shall inform the patient that if he desires to communicate with any person or persons they will be summoned, and any proper person or persons, not exceeding two, shall be permitted to have a full and unrestrained inter- view with the patient. The statements furnished at the time of the reception of the patient, and the statement of the medical attendant of the house, shall be sent to the committee on lunacy, and there shall be a report, at least once in six months, by the medical attendant, on the condition of each patient. 510 APPENDIX PENNSYLVANIA. Persons detained as insane may, under certain restrictions and regula- tions, have any medical practitioner they desire to treat them for all maladies other than insanity. All persons detained as insane shall, in the discretion of the superin- tendent, be allowed to correspond under seal with persons outside the asylum, and they shall have the unrestricted privilege of Avriting once a month to any member of the committee on lunacy. All persons other than criminals, who have been detained as insane, shall, as soon as they are restored to reason, in the opinion of the medical attendant of the house, be forthwith discharged. If the discharged patient is in indigent circumstances, he shall be furnished with raiment and with funds sufficient to travel to his home. The committee on lunacy shall be notified of all discharges within seven days thereafter. The committee on lunacy may at any time order the discharge of a patient (other than a person committed after trial and conviction for crime, or by order of court). But such order shall not be made unless notice is first given to the person in charge of the asylum, and to the persons who caused the patient to be detained, and the committee shall not sign an order for discharge unless they have personally examined the case of the patient. Persons may voluntarily place themselves in an asylum for a period not exceeding seven days, by signing an agreement giving authority to detain them, and they may from time to time renew the authority for periods not exceeding seven days each ; but every such agreement must be signed in the presence of some adult person attending as a friend of the patient. Such agreement must also be signed in the presence of the person in charge of the house, or the medical attendant, who shall him- self subscribe it. Whenever the State Board of Commissioners of Public Charities shall deem it expedient to transfer any indigent insane person in a county poor-house, or almshouse, or otherwise in the custody of the directors or overseers of the poor, to the State hospitals for the insane for care and treatment, they shall petition the president judge of the court of common pleas of the proper county, who shall notify the directors or overseers of the poor to appear, and show cause why such removal should not take place. If, upon hearing, the judge deem it best, he shall make an order directing the removal of such insane person to the State hospital for the proper district. The expense of caring for indigent insane persons in the State hos- pitals shall be divided between the State and the county, the county not paying for each person over two dollars a week. Insane persons may be placed in a hospital by order of any court or law judge after the following course of proceedings : On statement in writing of any respectable person that a certain person is insane, and requires restraint, the judge shall appoint at once a commission to inquire into, and report on, the facts of the case. This commission shall be com- posed of three persons, one of whom, at least, shall be a physician, and another a lawyer. If, after hearing the evidence, they think it is a suit- APPENDIX PENNSYLVANIA. 511 able case for confinement, the judge shall issue his warrant for such dis- position of the insane person as the circumstances of the case require. If an insane person is manifestly suffering from want of proper care, any law judge shall order him to be placed in some hospital for the insane, at the expense of those legally bound to support him. But in every such case there muse be notice to the persons affected, and a hearing had in the matter. Persons who have voluntarily bound themselves for the support of any patient in the hospital, may remove the patient to avoid further responsibility. Pennsylvania State Lunatic Hospital. The admission of insane patients from the several counties shall be in the ratio of their insane population. Paying patients shall pay according to the terms directed by the trustees. Indigent persons and paupers shall be supported in the hospital by the townships and counties to which they are chargeable. The several constituted authorities having care of the poor in the several counties and towns shall have authority to send to the asylum such insane paupers as they deem proper inmates. If any person shall apply to any court of record, having jurisdiction of offences which are punishable by imprisonment for ninety days or more, for the commitment to the asylum of any insane person within the county, it shall be lawful for such court to either inquire into the fact of insanity in a summary way, giving due notice to the alleged lunatic and his friends or kindred, or by awarding an inquest, at the option of the court. If the court is satisfied that such person is by reason of insanity unfit to be at large, or is suffering any unnecessary duress or hardship, it shall commit the person to the asylum ; but in all cases the court may use its discretion in sending any insane person to the hospital, and may cause him to be confined elsewhere if it believes the case incurable. In order of admission, the indigent are to have precedence over the rich, and if there is not room for all, recent cases shall have preference over those of long standing. The friends or relatives of any insane person, a patient in the hospital, may apply to the court of common pleas of Dauphin County, or to the president judge of said court in vacation, to deliver over to them the person there confined. The court or judge, if it is safe for the com- munity, may do this, provided security is given that such lunatic shall do no injury to the person or property of anyone when at large. The courts may commit to the asylum any person who, having been charged with an offence punishable by imprisonment or death, shall be found to have been insane at the time the offence was committed, and who still continues insane. If any prisoner confined in the Eastern Penitentiary develops such marked insanity as to render continued confinement in the penitentiary improper, and removal to the State Lunatic Hospital necessary to his restoration, the inspectors of the penitentiary shall submit the case to a board composed of the district attorney of the county of Philadelphia, the principal physician of the Pennsylvania Hospital for the Insane at Philadelphia, and the principal physician of the Friends' Insane Asylum at Frankford, and in case a majority cannot at any time when required attend, a competent physician or physicians shall be appointed by the 512 APPENDIX PENNSYLVANIA. court of quarter sessions of the county of Philadelphia in the place or such as cannot attend. If any two of the board certify that the prisoner is insane, the Governor shall, if he approves, direct that the insane pris- oner be removed to the State Lunatic Hospital. If any such insane prisoner in the hospital so far recovers, before his sentence has expired, that his return to the penitentiary will be safe and proper, the trustees shall cause such prisoner to be returned to the penitentiary. Due notice of all such removals or transfers shall be given to the clerk of the court of quarter sessions of the county from which such prisoners were sent to the penitentiary. No person shall be sent to this lunatic hospital who shall have been charged with homicide, or of having attempted to commit the same, or to commit any arson, rape, robbery, or burglary, and have been acquitted of any such offence on the ground of insanity. Where the court trying such person, or hearing the case, shall be satisfied that it is dangerous for such lunatic to be at large on account of having committed or attempted to commit either of the crimes aforesaid, such person shall be continued in the penitentiary or the prison of the county ; provided that the court may send the person to said lunatic hospital, if it is satisfied that a cure of the insanity may be speedily effected by so doing. In every case of an insane criminal or a dangerous lunatic sent to the asylum, if the trustees of the asylum and the superintending physician are satisfied there is no reasonable prospect of a cure of the insanity being effected by a retention of the lunatic in the hospital, they shall cause him to be removed to the prison of the proper county, or to the penitentiary from which he was sent. Western Pennsylvania Hospital. Beside provisions in substance the same as those in regard to commitment to and discharge from the Penn- sylvania State Lunatic Hospital, it is further specially provided as follows : Any indigent insane patients, not criminals, that are regarded by the board of managers of the hospital and the physician as incurable, shall be returned to the constituted authorities having charge of the poor in the city, township, or poor district, which may be chargeable with the support of such poor patients. If any criminal a patient in the hospital recovers his sanity, the sheriff shall be notified, and thereupon such sheriff shall remove such person to the jail of the proper county, there to be held in strict custody subject to the further order, decree, or sentence of the court by which he was committed to the hospital. If any indigent patient is cured of his insanity, the principal physician shall notify the commissioners of the proper county to remove such cured person from the hospital. If any county liable for the support of insane patients fails for a period of three months to pay the amount due for such support, the managers of the hospital may return to the jail of the said county those insane persons whose expenses remain unpaid, excepting those cases which have been sent to the hospital from the penitentiary. Miscellaneous Provisions. It shall be lawful for any court of common pleas to issue a commission to inquire into the lunacy of any person in the commonwealth, or having property therein. On the return of any inquisition finding that the person named is a lunatic, the court may APPENDIX PENNSYLVANIA. 513 commit the custody and care of the person, or estate, or both, to such person or persons as they deem most suitable. Whenever any person shall be found by inquisition to be insane, the committee of the person or of the estate of such insane person, and also the clerk of the court into which the inquisition has been returned, shall forthwith send to the committee on lunacy a statement signed by the committee of the lunatic giving the name, age, sex, and residence of the lunatic, and the residence of the committee ; and, upon any change in the residence or place of detention of the lunatic, notice shall forthwith be given to the committee on lunacy. The committee on lunacy shall have power to visit, examine, and look after such lunatic, and may apply to the proper court to make such orders for the care or maintenance of the lunatic as the case may require. Appeal from any order thus made may be taken to the supreme court. Adjudged lunatics shall not be arrested on civil process, and, if they are so arrested, shall be discharged by the court from which the process issued. If any person not an adjudged lunatic is imprisoned in any civil action and appears to be insane, the jailer shall notify two or more aldermen or justices of the peace, who shall attend at the jail and make an examina- tion, and, if they find the prisoner of unsound mind, they shall certify the same to the prothonotary of the court of common pleas of the county. He shall bring the matter before the court, and a day shall be fixed for a hearing, and the creditor, plaintiff in the case, shall be notified. If the court, on hearing the case, is satisfied that the prisoner is insane, an order shall be made for his discharge from confinement ; provided that if it appears to the court that he is not fit to go at large, the court may make an order that he be detained in custody or delivered to his kindred or friends in the manner provided in the case of a lunatic charged with a crime or misdemeanor. Whenever upon the trial of any person charged with a crime or mis- demeanor it is given in evidence that such person was insane at the time of the commission of such offence, and he is acquitted by the jury especially on this ground, the court may order him to be committed to some place of confinement for safe keeping or treatment. If after a confinement of three months any law judge is satisfied that the prisoner has recovered, and that the pai'oxysm of insanity in which the criminal act was com- mitted was the first and only one he had ever experienced, he may order his unconditional discharge ; if, however, it appear that such paroxysm of insanity was preceded by at least one other, then the court may in its discretion appoint a guardian of his person and commit the care of the prisoner to him, the guardian giving bonds to pay for any damage his ward may commit ; provided always, that in case of homicide, or attempted homicide, the prisoner shall not be discharged unless, in the unanimous opinion of the superintendent and the managers of the hospital and the court before which the prisoner was tried, he has recovered and is safe to be at large. If a person indicted for an offence shall, upon arraignment or upon the trial, be found to be a lunatic, the court shall proceed to confine him as above stated. In every case in which a person charged with any offence is brought before the court to be discharged for want of prosecution, and shall, by the oath of one or more credible persons, 33 514 APPENDIX PENNSYLVANIA. appear to be insane, the court shall order the district attorney to send before the grand jury a written allegation of such insanity, and the grand jury shall make inquiry into the case, and make presentment of their finding, and thereupon the court shall order a jury to be impanelled to try the insanity of such person. Notice of the trial shall be given to the next of kin, and, if the jury find such person insane, he shall be committed by the court as aforesaid. If the kindred or friends of any person who may have been acquitted as aforesaid on the ground of insanity, or, in default of such kindred or friends, the guardians, overseers, or supervisors of any county, township, or place, shall give proper security that such lunatic shall be restrained from the commission of any offence, the court may make an order for his delivery to his kindred or friends, or to such guardians, overseers, or supervisors. Whenever any person is imprisoned, either convicted of any crime, or charged with any crime, and acquitted on the ground of insanity, appli- cation in writing, under oath, stating that such prisoner is believed to be insane, and requesting that such prisoner be removed to a hospital for the insane, may be made to any judge of any court having immediate cognizance of the crime with which such prisoner is charged, or of the court by which such prisoner has been convicted, to appoint a commission of three citizens. One of the commissioners shall be of the profession of medicine and one of the profession of law, and it shall be their duty to inquire into and report upon the mental condition of the prisoner. If, by the report of the commissioners, it appears that the prisoner is of unsound mind and unfit for penal discipline, the judge issuing the com- mission, or any other judge of the same court, may make an order di- recting the removal of such prisoner to the State Hospital for the Insane nearest to the place of imprisonment, there to be kept and cared for : Provided, that whenever a hospital is established by the State especially for the care of insane crimirals, the order of removal shall be to that hospital. In all cases where any person who may have committed any criminal act and is dangerous to the community shall be found to be insane in the manner provided by law, any court having cognizance of the offence with which such person is charged may commit him to the proper asylum for the insane, to remain until restored to sanity. Whenever any person sent to the hospital under these provisions has been so far restored to mental sanity as no longer to need the care or restraint of the hospital, the judge who committed him may, if the term of imprisonment for which such prisoner was sentenced has not expired, remand him to prison to serve out the unexpired term of sentence, or if such prisoner became unsound in mind after the alleged crime and before conviction, the judge may remand such prisoner for trial ; but, if the term for which such prisoner was sentenced has expired, or if the crime with which the prisoner is charged was committed during his probable insanity, the judge may order the patient to be discharged. If the term of sentence expires while the prisoner remains uncured in the hospital, the judge, upon the due application of relatives or friends of such patient, and upon proper security being given for the custody and care of such APPENDIX RHODE ISLAND. 515 insane person, may make an order for his discharge from the hospital and delivery into the control of the person or persons applying therefor. Insane criminals in custody shall not be received into an asylum except when delivered by a sheriff of the county, or his deputy, together with an order of the proper court. Nor shall such criminals be discharged from a hospital, or other place of detention, save on a like order, and to the sheriff, or his deputy, producing the order. Whenever any person detained in any jail or prison is insane, or in such a condition as to require treatment in a hospital for the insane, it shall be the duty of any law judge of the court, under whose order the person is detained, upon application, to direct an inquiry into the circum- stances, either by a commission or otherwise, as he shall deem proper, with notice to the committee on lunacy ; and, if the judge shall be satisfied that the prisoner requires treatment in a hospital, he shall direct the re- moval of the person from the jail or prison to a State hospital. The trustees, managers, and physician of any hospital in which a criminal is confined by order of any court, or to which a lunatic has been committed after an acquittal of crime, shall not discharge the prisoner, or lunatic, without the order of a court of competent jurisdic- tion ; and in case such lunatic, whether a convict or acquitted, is not set at large, but is to be removed to any place of custody other than a hos- pital, the order for removal shall not be made without notice to the com- mittee of lunacy, and time given them to investigate the case and be heard. RHODE ISLAND. 1 Whenever any person is a lunatic, or so furiously mad as to render it dangerous for him to be at large, any trial justice or clerk of a justice court within the county, on complaint in writing, under oath, shall issue his warrant, directing that such person be brought before that or some other justice court for examination. If the court, on such examination, find the complaint true, it shall, unless- security is given that said insane person shall not be permitted to go at large until restored to soundness of mind, commit such person either to the Butler Hospital for the Insane or to the State Asylum for the Insane. Such patient shall be detained in the hospital until it is found by some justice court of the county where he is detained that he is restored to soundness of mind, or is no longer under need of restraint, or until security is given to the court, as afore- said, for his safe keeping. The expense of caring for any such lunatic shall be paid out of his estate, if he has any ; if he has no estate, then by the town liable for his support. 1 Public Statutes of Khode Island, 1882, pp. 195-204, 425, 430, 446, 467, 720. Acts and Resolves, R. I., January session, 1883, pp. 129, 130, 146. 516 APPENDIX RHODE ISLAND. On petition, stating that any person is insane, and ought to be placed in a hospital, or restrained, any justice of the supreme court may forth- with appoint not less than three commissioners to inquire into and report all facts bearing on the case, together with their opinion whether such person, if insane, should be placed in one of the insane asylums. The commissioners shall fix a time for a hearing, give notice to the party alleged to be insane, hear all evidence offered, and make an examination of the supposed insane person. The court may, pending the inquisition, give directions for the care and restraint of such insane person, and may, if necessary, commit him to one of the asylums, or to the county jail, as is most convenient and proper. On the coming in of the report of the commissioners, the justice may order the person complained of to be con- fined in the Butler Hospital for the Insane, or at the State Asylum for the Insane, or in some other curative hospital for the insane of good repute within or without the State, or may dismiss the petition altogether. Any person thus committed may, although not restored to sanity, be discharged from the asylum upon the written recommendation of the trustees and superintendent of the asylum, by an order of any justice of the supreme court, made in his discretion. The parents or guardian of any insane person, if he have any, and, if not, his relatives and friends, or, if a pauper, the overseers of the poor of the town to which he is chargeable, may have him removed to and placed in the Butler Hospital or State Asylum for the Insane, if he can be there received ; and if not, in any other hospital for the insane of good repute, managed under the supervision of a board of officers ap- pointed under the authority of this or some other State; but the super- intendent of such hospital shall not receive any person into his custody in such case without a certificate from two practising physicians of good standing that such person is insane. Any persons who, of their own accord, without any obligation imposed by law, have become responsible for the payment of the expenses of any insane person in an asylum, may, if it is necessary in order to terminate further responsibility on their part, remove such person therefrom. The superintendent of any asylum for the insane within the State may, on the application of any relative or friend, and with the approba- tion in writing of the visiting committee of the trustees, discharge any person not committed by process of law. On petition to a justice of the supieme court by some person, not an inmate of the asylum, setting forth that he has reason to believe, and does believe, that a person confined therein is not insane, and is unjustly de- prived of his liberty, the justice, in his discretion, may issue a commission, such as has been described above, to inquire into the patient's condition. No person shall visit or examine the patient, except the commissioners, and they only at the asylum, and not elsewhere. On the coming in of the commissioners' report, the court may confirm or disallow the same, and order the discharge of such person, or dismiss the petition altogether, as the truth shall seem to require. It is not intended by any of these provisions to impair or abridge the right to the writ of habeas corpus. No commission for the purpose of committing or discharging an insane person shall be issued by a justice of the supreme court, as above stated, APPENDIX RHODE ISLAND. 517 until the person applying therefor has given security for the payment of all expenses of the proceedings, and for the support of the insane person in the asylum, if committed thereto. Whenever any person imprisoned, awaiting trial, in a criminal case, is deemed insane, the Agent of State Charities and Corrections, or the clerk of the supreme court or court of common pleas, in any county of the State other than the county of Providence, may petition any justice of the supreme court to make an examination. If, upon such examination, the justice is satisfied that the person thus imprisoned is insane or idiotic, he may order the removal of such prisoner from the jail to the State Asylum for the Insane, if he can be there received ; if not, to the Butler Hospital for the Insane. Upon the restoration to reason of any person so removed, any one of the justices of the supreme court, in his discre- tion, may order that the prisoner be remanded to the place of his original confinement, to await his trial for the offence for which he stands com- mitted. Whenever, on the trial of any person upon an indictment, the accused shall set up in defence his insanity, and the jury shall acquit him on that ground, the court, if it deem the going at large of such person dangerous to the public peace, shall certify its opinion to the Governor of the State. The Governor may make provision for the support of the person so acquitted, and cause him to be removed to the State Asylum for the Insane, or other institution for the insane, either within or without the State, during the continuance of such insanity. The expenses of his maintenance shall be paid by the State, but may be collected out of the estate of such insane person, if he has any. On petition of the Board of State Charities and Corrections, stating that any person convicted of crime, and imprisoned for the same in the State Prison, or in the Providence county jail ; or, on petition of the clerks of the supreme court or court of common pleas, in the other counties of the State, that any convict in the jails of their respective counties is insane, idiotic, or in such a state of impairment of body, or mind, or both, as tends directly to insanity, idiocy, or dementia, or to a permanent incapa- city for mental or physical labor, any justice of the supreme court may, in his discretion, order an examination. If, upon such examination, said justice is satisfied that the convict is insane, or in any of the states of mind or body above mentioned, he may order the removal of such pris- oner from the State Prison, or any of the said jails, to the State Asylum for the Insane, the State Almshouse, or to Butler Hospital, as, in his judgment, he shall deem best. Such order of removal shall be only during the term, and until the expiration of the prisoner's sentence. Upon restoration to reason or to health, both of body and mind, of the prisoner, either of the justices of the supreme court may, in his discre- tion, remand him to the place of his original confinement, to serve out the remainder of his term of sentence. The Agent of State Charities and Corrections and the Secretary of State shall constitute a commission to visit and examine all places and institu- tions in the State where insane persons are confined, and to receive and examine all complaints, communications, and letters from, or relating to, any insane person, or person alleged to be insane. They shall investigate 518 APPENDIX SOUTH CAROLINA. any case that seems to require it, and, in their discretion, may petition a justice of the supreme court to have an examination made of any person's condition, in the manner above described, and said justice may, in his discretion, cause the person restrained to be discharged. Whenever the Agent of State Charities and Corrections shall make complaint, in writing, to the supreme court that any person reputed to be idiotic, lunatic, or insane, is not humanely or properly cared for, or is improperly restrained of his liberty, in any town, the court shall examine into the circumstances of the case, and, if the complaint is found true, shall order and cause such idiotic, lunatic, or insane person to be removed to the State Asylum for the Insane. Every pauper lunatic, having no legal settlement in the State, who, in the opinion of the Board of State Charities and Corrections, is insane, shall be sent by said board to the State Almshouse, or to the State Asylum for the Insane, there to be maintained at the expense of the State. The board may send to this asylum any insane pauper who has a legal settle- ment in any town, to be kept on such terms as may be agreed upon. The Agent of State Charities and Corrections shall visit all town asylums and all places where any insane person is kept, to see that no insane person is improperly confined or improperly cared for, and he may discharge at any time from any institution any insane person who has been committed thereto upon his order. No insane pauper shall be detained in any town asylum, poor-house, lockup, or bridewell for a longer period than five days, unless, in the opinion of the Agent of State Charities and Correc- tions, he is properly cared for. The Board of State Charities and Corrections may receive for treatment and care any person who shall be an inhabitant of the State who, in their opinion, is insane, upon such terms for treatment and care as may be agreed upon between said board and some responsible person, upon the written certificate of two practising physicians that, in their opinion, such person is insane. SOUTH CAROLINA. 1 The following persons shall be entitled to admission as patients to the State Hospital for the Insane : (1) All persons found to be idiots or lunatics by inquisition from the probate or circuit courts, or on trial in the circuit court. (2) Where the admission is requested by the husband or wife, or, where there is no husband or wife, by the next of kin of the idiot or lunatic. (3) All persons declared lunatics, idiots, or epileptics, after due examination by one trial justice and two licensed 1 General Statutes of South Carolina, 1882, pp. 25, 270, 472-476, 751. The Code of Civil Procedure of South Carolina [bound with Gen. Stats.], pp. 15, 21, 22. APPENDIX SOUTH CAROLINA. 519 practising physicians of the State. In the case of a pauper, the ad- mission shall be at the request of the county commissioners of the county where the pauper has his legal settlement ; otherwise the admis- sion shall be at the request of the husband or wife or next of kin of the idiot, lunatic, or epileptic. Idiots and lunatics from other States may, when there is room in the asylum, be admitted on such evidence of their lunacy or idiocy as the regents regard sufficient, and they shall pay the same rates as citizen subjects. No lunatic, idiot, or epileptic, declared a fit subject for the asylum by a trial justice and two physicians, or sent from another State, shall be retained in the institution more than ten days, unless an order for his retention is made by the medical attendant and three, at least, of the regents of the asylum after a full examination of the patient's state of mind. Upon such order being made, the secretary of the board of regents shall make out certified copies of the papers in the case and send them to the judge of probate of the county where the patient resides, and said judge shall thereupon make such order in regard to the custody of the estate of the lunatic as would have been made had the proceedings been under a writ de lunatico inquirendo. Whenever a judge of probate or a judge of the circuit court shall direct any trial justice to inquire as to the idiocy, lunacy, or epilepsy of any person, or when information on oath shall be given to any trial justice that a person is an idiot, lunatic, or epileptic, and is a pauper, such trial justice forthwith shall call to his assistance two licensed practising physicians and examine such person and hear the evidence in the case. If after full examination they find such person an idiot, lunatic, or epileptic, they shall certify either to the said judge or to the board of county commissioners whether, in their opinion, such person is curable or incurable, and whether or not he is dangerous to be at large, and thereupon the judge or the board of county commissioners, in his or its discretion, may order that the person be sent to the lunatic asylum. The judge of the probate court may commit to the lunatic asylum any idiot, lunatic, or person non compos mentis, who, in his opinion, is so furiously mad as to be unfit to be at large. In all cases the judge shall certify in what place the said person resided. No patient shall be admitted to the asylum until the expenses of one- half year, or of such shorter time as the nature of the case seems to require, shall be paid in advance. A bond shall be given to secure the payment of all expenses ; but such bond shall not be required of the county commissioners sending a pauper patient to the institution. Whenever any lunatic or epileptic shall have recovered, it shall be the duty of the regents to discharge him from the asylum. Upon due notice from the superintendent of the asylum, the county commissioners of the various counties shall remove their imbeciles from the asylum, and shall take care of such persons in their respective county poor-houses. It has been recently enacted that before any insane person not offered as a pay patient is admitted to the asylum, the county commissioners shall investigate and see upon what footing the patient shall be admitted. 520 APPENDIX TENNESSEE. and whether or not he is able to pay some part of the expense of his support. In criminal cases, any judge of the circuit court is authorized to send to the lunatic asylum any person charged with the commission of any offence, who shall upon the trial before him prove to be non compos mentis, and the judge is authorized to make all necessary orders to carry into effect this power. No pauper lunatic, idiot, or epileptic, shall be confined for safe keeping in any jail ; and if any such person shall be imprisoned under, and by virtue of, any legal process, it shall be the duty of the sheriff, in Avhose custody he may be, to obtain his discharge as speedily as possible, and send him forthwith to the asylum, according to law. The county commissioners shall be authorized to send all pauper lunatics, idiots, and epileptics, in their several counties, to the lunatic asylum. TENNESSEE. 1 Each county is entitled to send to the hospital its due proportion, both of private and pauper patients, according to its population and the number of its insane, but not more than one non-paying patient to each four thousand inhabitants. Each senatorial district is entitled to send four pauper patients at the expense of the State. No person shall be received as a private patient except by an order of the attending physician of the hospital, or at least two of the board of trustees. When the friends of such person supposed to be insane offer to place him in the hospital he shall not be admitted until the trustees have caused inquiry to be made as to the state of his mind, and have found him to be insane. A sworn certificate of insanity, in prescribed form, from at least one respectable physician, must be produced, setting forth that the patient is free from any infectious disease, and giving a concise history of the patient and his disease. For the commitment of State patients, some respectable citizen of the county where the patient belongs shall file with a justice of the peace a statement, setting forth that the person is insane, that his insanity is of less than two years' duration, or that he is dangerous to be at large, that he is in needy circumstances, has a legal settlement in the county, and is a citizen of Tennessee. It shall also give the names of two persons, one of them a physician, who can testify to the facts stated. The justice shall summon the witnesses named, arid such others as he thinks proper. If, after inquest, the justice is satisfied of the truth of the statement, he 1 Statutes of Tennessee, 1871, Thompson & Steger, Vol. I. pp. 767-781 ; Vol. II. pp. 1516-1521, 1700; Vol. III. p. 271, 5488. Acts of Tennessee, 1873, pp. 74, 75, 97 ; 1877, p. 71 ; 1883, p. 195. APPENDIX TENNESSEE. 521 shall require the medical witnesses to make a certificate, such as is required in the case of a pay patient, in regard to history, condition, etc. The justice shall also make a certificate, stating that he has examined the patient and finds him insane and poor, and a fit subject for the hospital. A certificate of the facts shall be filed by the justice with the clerk of the county court. The clerk shall send a copy to the superintendent of the hospital and make application for the patient's commitment. If the superintendent says that he can be received, the clerk shall issue a warrant directing that the patient be conveyed to the hospital. Both the county courts and the chancery courts have jurisdiction to order an inquisition to be made into the sanity of any person, and to appoint a guardian for his person and property, if he is found insane. If a person so found to be an idiot or lunatic has no property, or not sufficient for his maintenance, he may be let out for the term of one year to the lowest bidder as other poor persons, or otherwise provided for as the court may direct. Security is to be taken by the court for the proper treatment of such person. Any justice of the peace in the recess of court, if satisfied from the finding of a jury, or otherwise, that there is danger of violence by such idiot or lunatic, may commit him to jail until the next term of the court. When the plea of present insanity is urged in behalf of any person charged with a criminal offence, punishable with imprisonment or death, and the jury find the defendant to be insane, and unsafe to be set at liberty, the court shall order the superintendent of the Hospital for the Insane to receive and keep the defendant as other lunatics are kept. When, in the opinion of the trustees and physician, such patient has re- covered from his insanity, they shall cause him to be delivered to the jailer of Davidson County for safe keeping, and shall send notice to the clerk of the county where the patient was arraigned. If, at the next term of the court, the district attorney wishes further to prosecute such person, he shall be taken to the county jail ; but, if the district attorney does not wish further to prosecute the prisoner, he shall be discharged. Whenever the physician of the penitentiary reports to the keeper that any convict is insane and ought, on that account, to be removed to the lunatic asylum, the keeper shall cause such insane convict to be so re- moved, to remain in the hospital until discharged by the physician of the lunatic asylum. The trustees of the Hospital for the Insane have power to discharge at any time any of the patients in the hospital, unless committed to custody in the same by some court. No persons not citizens of the State shall be admitted as patients in the Hospital for the Insane. 522 APPENDIX TEXAS. TEXAS. 1 The following persons may be admitted into the asylum as patients : 1. All persons who have been adjudged insane by a court of competent jurisdiction in this State arid ordered to be conveyed to the asylum. This class shall be known as public patients. 2. All persons who may be certified to be insane by some respectable physician, under the regulations hereafter stated. This class shall be known as private patients. Before any person can be admitted as a private patient the parent or legal guardian of such person, or, in case he has no parent or legal guardian, some near relative or other person interested in him, must present a written request to the superintendent for his admission, setting forth the name, age, and residence of the lunatic, with such other par- ticulars as may be required. This request must be under oath and ac- companied with the affidavit of the physician certifying to the insanity that he has made careful examination of the person and verily believes him to be insane. There must also be a certificate from the county judge of the county where the lunatic resides, that the examining physician is a respectable physician in regular practice. All private patients shall be kept at their own expense, or the expense of their relatives or friends. All public patients shall be kept at the expense of the State, but money so paid may be collected from the patient or those liable for his support, if they have property. If applications be made for the admission of more patients than can be accommodated in the asylum, preference shall be given, in all instances, to public over private patients, and of the former class to cases of less than one year's duration over chronic cases, and to indigent patients over those possessed of property ; and no private patients shall be admitted during the pendency of an application by a public patient, nor shall any public non-indigent patient be admitted during the pendency of an appli- cation by an indigent public patient. No idiot who can be safely kept in the county to which he belongs, nor any person with an infectious or contagious disease, shall be received into the asylum as a patient. Any patient (except such as are charged with, or convicted of, some offence and have been adjudged insane in accordance with the provisions of the Code of Criminal Procedure) may be discharged from the asylum at any time upon the recommendation of the superintendent, approved by the board of managers. Any patient coming within the above ex- ception can only be discharged by order of the court by which he was committed. No patient shall be discharged without suitable clothing, and money 1 Revised Statutes of Texas, 1879, pp. 20-26, 386, 387. Penal Code [bound with Revised Statutes], p. 5. Code of Criminal Procedure [bound with Revised Statutes], pp. 66, 86, 112, 113. General Laws of Texas, 1883, pp. 9-11, 103-105. APPENDIX TEXAS. 523 sufficient to pay his expenses home. If discharged uncured, he shall be conveyed, under guard, to his friends, or to the county from which he was sent. If information in writing, under oath, be given to any county judge that any person in his county is a lunatic and ought to be placed under restraint, he shall, if he believes the statement, forthwith issue his warrant for the apprehension of such person, and shall fix a day for a hearing in the matter. He shall also have a jury of six competent persons of the county summoned to hear and determine the matter. The county attorney shall appear and represent the State, and the defendant shall be entitled to counsel, and in proper cases the court may appoint counsel for him. After the evidence is heard, the county judge shall submit the matter to the jury. Upon return of a verdict finding that the defendant is of usound mind, and that it is necessary that he be placed under restraint, judgment shall be entered adjudging him to be a lunatic and ordering him to be conveyed to the lunatic asylum for restraint and treatment. Immediately after any person is adjudged a lunatic the county judge shall communicate with the superintendent of the asylum, and, if notified that the patient can be accommodated, he shall issue his warrant to have the lunatic conveyed to the asylum without delay. No lunatic shall be taken to the asylum if some relative or friend will undertake, before the county judge, his care and restraint, giving a sufficient bond therefor. The proceedings in any inquisition of lunacy shall be entered of record in the county court, and a transcript made of the same and sent to the superintendent of the asylum when the patient is sent there. The county judge shall see that the patient is supplied with proper clothing before sending him to the asylum. No act done in a state of insanity can be punished as an offence. No person who becomes insane after he committed an offence shall be tried for the same while in such condition. No person who becomes insane after he is found guilty shall be punished for the offence while in such condition. Where the jury are of opinion that a person pleading guilty is insane, they shall so report to the court, and an issue as to that fact shall be tried before another jury. If upon such trial it be found that the de- fendant is insane, he shall be committed to the asylum in the same manner as where a defendant is found insane after conviction. If it be made known to the court at any time after conviction, or if the court has good reason to believe, that a defendant is insane, a jury shall be impanelled to try the issue. If the defendant has no counsel, the court shall appoint counsel for him. When a defendant is found by the jury to be insane, the court shall make an order committing the de- fendant to the custody of the sheriff. The proceedings shall then forth- with be certified to the county judge, who shall take the necessary steps at once to have the defendant confined in the lunatic asylum until he becomes sane. Should the defendant become sane, he shall be brought before the court in which he was convicted, and a jury shall again be impanelled to try the issue of his sanity ; and should he be found to be sane, the conviction shall be enforced against him in the same manner as 524 APPENDIX UTAH. if the proceedings had never been suspended ; if found insane, he shall be remanded to the lunatic asylum. The judge of the county court may, on proper information and pro- ceedings, appoint a guardian for any person of unsound mind. If any person shall be furiously mad or so far disordered in his mind as to endanger his own person or the property of others, it shall be the duty of the guardian or other person, under whose care he may be, to confine him in some suitable place until the first regular term of the county court of his county, when the court shall make such order for the restraint, support, and safe keeping of such person as the circumstances may re- quire. If the persons having charge of such an insane person do not confine him, or if there be no one in charge of him, any magistrate may cause him to be apprehended, and may employ any person to confine him in some suitable place until the county court makes further order in regard to him. UTAH. 1 (TERRITORY.) Patients may be admitted to the asylum in the following manner : The probate judge of any county shall, upon application, under oath, setting forth that a person, by reason of insanity, is dangerous to be at large, cause such person to be brought before him, and shall summon to appear at the same time two or more witnesses who well knew the person alleged to be insane, who shall testify as to his conversation, manners, and gen- eral conduct ; and the judge shall also cause to appear, at the same time, two practising physicians, who shall be present during the hearing. If, after a hearing of the evidence, and a personal examination of the alleged insane person, the physicians shall certify that the person is insane, and the case is of a recent or curable character, or that the insane person is of a homicidal, suicidal, or incendiary disposition, or that from any other violent symptoms he would be dangerous to be at large, the judge, if con- vinced that the facts are in accordance with the physicians' certificate, shall direct the sheriff or some suitable person to convey to, and place in charge of the officers of, the Territorial Insane Asylum such insane person. The physicians shall also certify to the name, age, nativity, resi- dence, occupation, length of time in the Territory, State or country last lived in, previous habits, premonitory symptoms, apparent cause and class of insanity, duration of the disease and present condition, as nearly as may be ascertained by examination and inquiry. A copy of the com- plaint, commitment, and physicians' certificate shall be sent to the medi- cal superintendent of the asylum. No case of idiocy, imbecility, harmless chronic mental unsoundness or delirium tremens shall be committed to the asylum. If any persons of 1 Laws of Utah, 1878, pp. 134, 135, 159-161 ; 1880, pp. 57-65, 75; 1882, p. 32. APPENDIX UTAH. 525 either of these classes are unlawfully placed in the asylum, the superin- tendent may discharge them and return them to the county from which they were committed. If an insane person committed to the asylum has property, the judge shall appoint a guardian to take charge of the same, and apply it to paying the expenses of the insane person in the asylum. The kindred or friends of an inmate of the asylum may receive such inmate therefrom, upon giving satisfactory evidence that they are capable and suited to take charge of, and give proper care to, such insane person, and exercise proper restraint over him. If the evidence satisfies the judge on these points, he may make an order, directed to the medical superintendent of the asylum, for the removal of such person. If, after such removal, the insane person is not properly cared for or restrained, the judge may order him to be returned to the asylum. Non-residents of the Territory shall not be committed to, nor supported in, the asylum, except temporarily, until they can be returned to their home or friends. Indigent patients shall be supported in the asylum by the county from which they are sent. A person cannot be tried, adjudged to punishment, or punished for a public oifence while he is insane. When an indictment is called for trial, if a doubt arises as to the sanity of the defendant, the court must order the question to be submitted to a jury ; when such doubt arises on the defendant being brought up for judgment on conviction, the court must order a jury to be summoned from the list of jurors provided by law to inquire into the fact, and the trial of the indictment, or the pronouncing of the judgment, must be suspended until the question of insanity is determined by the verdict of the jury. If the jury find the defendant insane, the trial or judgment must be suspended until he becomes sane, and the court, if it deems his discharge dangerous to the public peace or safety, may order that he be in the mean time committed by the proper officer to a lunatic asylum. If the defendant is received into an asylum, he must be detained there until he becomes sane, when he must be brought from the asylum and placed in proper custody until he is brought to trial or judgment, as the case may be, or is legally discharged. If, after judgment of death, there is good reason to suppose that the defendant has become insane, the proper officer, with the concurrence of the judge of the court by which the judgment was rendered, may sum- mon from the list of jurors selected by the proper officers for the year a jury of twelve persons to inquire into the supposed insanity. The prose- cuting attorney must attend the inquisition, and may produce witnesses. If it is found by the inquisition that the defendant is insane, the officer must suspend the execution of the judgment until he receives a warrant from the Governor, or from the judge of the court by which the judg- ment was rendered, directing the execution. The Governor, when the defendant becomes sane, may appoint a day for the execution of the judgment. 526 APPENDIX VERMONT. VERMONT. 1 No person shall be admitted to, or detained in, an insane asylum as a patient or inmate, except upon the certificate of such person's insanity, stating the reasons for adjudging such person insane, made by two physicians of unquestioned integrity and skill, residing in the probate district in which such insane person resides, or, if such insane person is not a resident of the State, in the probate district in which the asylum is situated ; or if such insane person is a convict in the State Prison or House of Correction, such physicians may be residents of the probate district in which such place of confinement is situated. The two physicians making such certificate shall not be members of the same firm and neither shall be an officer of an insane asylum of this State. The next friend or relative of a person thus found insane, may appeal to the supervisors of the insane. The supervisors shall exrimine the case, the examination being had in the town where the appellant resides. Pending the appeal, the patient shall not be committed to the asylum. If the supervisors find that there was not sufficient ground for making the certificate, they shall declare it void. Idiots and persons non compos, who are not dangerous, shall not be confined in an asylum for the insane, and, if any such persons are 30 confined, the supervisors of the insane shall cause them to be discharged. The physicians' certificate, above mentioned, shall be made not more than ten days previous to the admission of such insane person to the asylum and not more than five days after making a careful examination. There must be a certificate of the judge of probate of the district in which the physicians reside, that the physicians are of unquestioned integrity and skill in their profession. This certificate shall be presented to the proper officer of the asylum at the time the patient is presented for admission. Any physician signing a certificate without first making a careful exami- nation of the supposed insane person, shall be liable to a penalty of from $50 to $100, in case the person is sent to an asylum on such certificate. A person may be received into an asylum without a certificate, by the order or sentence of the supreme or county court, upon the presentation of a certified copy of the order or sentence. If the probate judge, in a case duly brought before him by the select- men of a town and the State's attorney, finds that an insane person is without a settlement in any town and is liable to be supported by the State, and the insanity of such person is certified to by two physicians of unquestioned skill and integrity, resident in said probate district, who are duly indorsed by said judge, the judge shall issue an order for the removal of such insane person to the Vermont Asylum for the Insane, to be there supported. The officer, or other person appointed by the judge to transport such insane person to the asylum, shall leave with the super- 1 Revised Laws of Vermont, 1880, pp. 355, 491, 559-565, 813, 844. Laws of Ver- mont, 1882, pp. 55-59. APPENDIX VERMONT. 527 intendent, or one of the trustees of the asylum, a copy of the judge's order and also a copy of the physicians' certificate indorsed by the judge. When such person is lawfully discharged from the asylum, the town causing him to be removed thereto shall take charge of and support him again. No patient shall be supported in the asylum entirely at the expense of the State unless he is sent there upon the order of a probate judge, or from the State Prison or House of Correction, or upon the order or sen- tence of the county or supreme court. Insane town paupers or insane persons in indigent circumstances shall be supported by the town where they belong, at the Vermont Asylum for the Insane. The selectmen may make contracts with the officers of the asylum for their support. If a person is insane and his property is not sufficient to support himself and his wife and children, his wife may complain to the county court in the county where such insane person has his settlement, and the court, after a hearing, may order the town to support the insane person at the asylum. In certain cases the State will pay a part of the expenses of poor patients placed in the hospital by the selectmen of a town. There shall be three supervisors of the insane elected by the general assembly, two of whom shall be physicians, and none of them shall be a trustee or officer of an insane asylum in the State. The supervisors shall visit every asylum for the insane in the State, one of the board as often as once a month, and they shall examine into the management and condition of the patients, and they shall particularly ascertain whether persons are confined in any asylum who ought to be discharged, and they may make such orders as any case requires. The supervisors may discharge, by their order in writing, any person confined as a patient in any asylum for the insane whom they find, on investigation, to be wrongfully confined, or whom they find so far sane as to warrant dis- charge. But convicts sent to the asylum from the State Prison or House of Correction, who are found insane before the expiration of their sentence, shall not be discharged, but shall be returned to the prison or house of correction. In no case shall the supervisors order the discharge of a patient without giving the superintendent of the asylum an opportunity to be heard. The Governor may refer the case of any patient in the asylums for the insane to the supervisors for their investigation. If in any case they have not the power to grant the necessary relief, they shall, if the patient is one of the insane poor of the State, cause such proceedings to be com- menced in court as are necessary to obtain the required relief. The friends or relatives of a patient may apply to the supervisors to inquire into the treatment and confinement of such patient, and the supervisors shall take such action upon such application as it requires. If a trustee, superintendent, employe, or other officer of an asylum for the insane wilfully and knowingly neglects or refuses to discharge a patient after such patient has become sane, or after the supervisors have .ordered his discharge, he shall be fined not more than $500. It shall be the duty of the legal guardian of any insane person not a pauper, and the duty of the overseer of the poor of the town in which any insane person who is a pauper resides, when such insane person 528 APPENDIX VERMONT. i is not placed in an asylum, to keep such insane person under such restraint as may be necessary to prevent his going at large. If any insane person, not a pauper, found going at large in any town, shall have no legally appointed guardian, application for the appointment of a guardian over him may be made to the probate court of the district in which such insane person resides by the selectmen of the town where such insane person is going at large. When a person held in prison on a charge of having committed an oifence is not indicted by the grand jury by reason of insanity, the grand jury shall so certify to the court, and thereupon if the discharge or going at large of such insane person is deemed manifestly dangerous to the community, the court may order him confined in the county jail or in the insane asylum at Brattleboro or some other suitable place at his own expense if he has estate sufficient for the purpose, and, if not, at the expense of the State. When a person tried on an indictment or information for any crime or offence is acquitted by the jury by reason of insanity, the jury, in giving their verdict of not guilty, shall state that it is given for such cause, and thereupon, if the discharge or going at large of such insane person is considered dangerous, the court may order him, in its discretion, to be confined in the State Prison or in the insane asylum at Brattleboro, on such terms as the court directs. A person confined as insane under an order of court, after having been acquitted or not indicted because of his insanity, shall be discharged from confinement only by order of the county court for the county in which the order for confinement was made, upon petition therefor, and after notice to the State's attorney. In case such person is confined in the insane asylum at Brattleboro, and has no estate, such petition may be brought in his behalf by the supervisors of the insane at the expense of the State. The court thus petitioned may direct that such insane person be brought before it for hearing. If, upon hearing, it appears to the court that such person has become sane, and his discharge or going at large is not considered by the court dangerous to the community, the court shall order the discharge of such person from confinement. Otherwise the petition shall be dismissed and such person shall be recommitted to the place of confinement from which he was brought. When a person acquitted of any crime or offence because of his insanity is confined by order of the court, such court may, on petition and after notice to the State's attorney, alter the terms on which such person is confined. When a person confined in the house of correction or State Prison for a specified time, or for life, becomes insane, and proper certificates of that fact are made, the directors may cause such prisoner to be removed to the insane asylum at Brattleboro, on such terms as they deem just, there to remain until he becomes cured of his insanity, or until the expiration of the term for which he was committed to the prison or house of correction. If before the expiration of such term such person becomes sane, he shall be returned to the institution to which he was originally committed, and confined therein for the remainder of said term. A prisoner, who at APPENDIX VIRGINIA. 529 the expiration of his term of confinement remains insane, may be removed to the insane asylum at Brattleboro, and may be there kept, or, if already there, may remain at the expense of the State or of the town where he belotigs, or of the relatives bound to support him. VIRGINIA. 1 On an application on behalf of a person for his admission into an asylum, the examining board (directors of the asylum), if unanimous that he ought to be admitted, may receive him as a patient therein, pro- vided sufficient security is given for the payment of the patient's ex- penses, and his removal when required. Any justice who shall suspect any person in his county or corporation to be a lunatic shall have such person brought before him. He and two other justices shall inquire whether such person be a lunatic, and, for that purpose, summon his physician, if any, and any other witnesses. They shall, so far as the same are applicable, propound sixteen prescribed questions relating to the history and condition of the patient. If the said justices decide that the person is a lunatic, and ought to be confined, and ascertain that he is a citizen of the State, then, unless some person will give bond, with sufficient security, to restrain and take proper care of such lunatic, the justices shall order him to be taken to the nearest asylum, if there be room therein, and, if not, to the other. The written interrogatories and answers, and a written statement by the justices as to the fact of insanity, shall be sent with their order to the asylum. The sheriff or officer who is to execute the order of the justices shall ascertain whether there is a vacancy in the nearest asylum, arid, if there be none, he shall make inquiry of the other superintendents. Until it is ascer- tained that there is a vacancy, the patient shall be kept in the jail of the county or corporation. When such patient arrives at the asylum, the board of directors shall be assembled, as soon as may be, and, if they concur in opinion with the justices, they shall receive and register him as a patient. If they refuse to receive the lunatic, the officer in whose cus- tody he may be shall confine him in the jail of the county where he was examined until lawfully discharged or removed therefrom. If a person found insane is not sent to an asylum, he shall be placed in the hands of a committee of the person and estate. If a lunatic who is committed to jail, or received into an asylum, is found to be a non-resident of the State, he shall, as soon as practicable, be returned to his friends or to the proper authorities of the State where 1 Code of Virginia, 1873, pp. 714-725, 1241, 1247, 1248. Acts of Assembly, Vir- ginia, 1874, pp. 23, 24; 1875-76, p. 8; 1876-77, pp. 38, 39; 1877-78, pp. 215, 216; 1878-79, pp. 367, 368; 1881-82, pp 134, 135. 34 530 APPENDIX VIRGINIA. he belongs. No non-resident lunatic shall be admitted or retained in either asylum as a pay patient, except when there is a vacancy not applied for on behalf of any person residing in the State. The Governor is authorized to cause insane persons not now kept in either of the State lunatic asylums to be taken to and kept in such insane asylums beyond the limits of the State as he may select, and he may make all necessary arrangements with the persons having charge of such asylums. Insane persons of the naval service of the United States who may be sent to either asylum by the Secretary of the Navy may be received so long as there is room in the asylums, but when it shall become necessary for the purpose of accommodating insane persons who are citizens of the State, such insane persons of the naval service, or so many as may be necessary, shall be removed from the asylums and restored to the care of the Secretary of the Navy. Idiots may not be sent to, or kept in, the insane asylums, but shall be taken charge of by their committees or by the overseers of the poor. Except in the case of patients charged with crime, the board of any asylum, or the court of any county or corporation, may deliver any lunatic confined in such asylum, or in the jail of the county, to any friend who will give proper bond to take care of him, and where any lunatic not a criminal is deemed by the superintendent of any asylum both harmless and incurable, the board may deliver him, without any bond, to any friend who is willing and able to take care of him. If any person who has given bond and taken charge of a lunatic Avishes to be relieved of the care of him, he may deliver him to the sheriff of the county, or sergeant of the corporation, according to the condition of the bond. Such sheriff or sergeant shall carry the lunatic before a justice of his county or corporation, and the regular proceedings shall be had for committing the patient to an asylum. If a person who has given bond to take care of a lunatic desii'es to put him in an asylum, he may take the patient directly before a justice, and may perform all the duties that a sheriff or sergeant might perform in the matter of having him committed to the asylum. When a person in jail on a charge of having committed a criminal offence appears, from a certificate of a grand jury, or otherwise, to the satisfaction of the court in which he is held to answer, to have been insane at the time of committing the act, and continues to be so insane, the court, in its discretion, may order him to be sent to one of the lunatic asylums of the State, or to be delivered to his friends. If a court in which a person is held for trial see reasonable ground to doubt his sanity at the time of trial, it shall suspend the trial and impanel a jury to inquire into the insanity. If the jury find that the accused is insane, they shall inquire whether or not he was so at the time of the alleged offence. If they find that he was insane at that time, the court may dismiss the prosecution, and either discharge him or, to prevent his doing mischief, remand him to jail and order him to be removed thence to one of the lunatic asylums. If they find that he was not insane at the time the offence was committed, but has become so since, the court shall commit him to jail or order him to be confined in one of the asylums until he is so restored that he can be put on trial. APPENDIX WASHINGTON. 531 When a person tried for an offence is acquitted by the jury by reason of his being insane, the verdict shall state the fact, and thereupon the court may, if it deems him dangerous, order him to be committed to jail until he can be sent to one of the asylums. If, after conviction and before sentence of any person, the court see reasonable ground to doubt his sanity, it may impanel a jury to inquire into the fact as to his sanity, and sentence him or commit him to jail or to a lunatic asylum, according as the jury may find him to be insane or sane. When any person confined in an asylum and charged with crime, and subject to be tried therefor, or convicted of crime, shall be restored to sanity, the board shall give notice thereof to the clerk of the court by whose order, or by the order of the judge of which he was confined. Such clerk shall issue a precept requiring the prisoner to be brought from the asylum and committed to jail. When a prisoner is so brought from the asylum and committed to jail, or when it is found by the verdict of another jury that a prisoner whose trial or sentence was suspended by reason of his being found to be insane has been restored to reason, if he has already been convicted, he shall be sentenced ; if not, the trial shall be held as if no delay had occurred on account of his insanity. When any person not a criminal, confined in an asylum or jail as a lunatic, shall be restored to sanity, the board or the court, as the case may be, shall discharge him and give him a certificate thereof. When any person shall be confined in any jail as a lunatic, the jailer shall certify the fact to the court of the county or corporation at their next term. The court shall thereupon cause such person to be examined by two disinterested persons, who shall, as soon as may be, report the result thereof. The court shall then make such provision for the main- tenance and care of the patient as his condition may require. It shall, Avhen practicable and proper, contract with some fit person for the main- tenance and care of such lunatic out of the jail, and make allowance for the expense of such support not exceeding what is authorized for a lunatic confined in jail. The committee of an insane person appointed by the circuit or county courts shall be entitled to the custody and control of his person when he resides in the State and is not confined in an asylum or jail. WASHINGTON. 1 (TERRITORY.) No person laboring under any contagious or infectious disease shall be admitted to the lunatic hospital as patient. In admitting patients to, and retaining them in, the hospital, the indigent insane of the Territory shall 1 Washington Code and Appendix, 1881, pp. 203, 204, 276-281, 351, 388-394. 532 APPENDIX WASHINGTON. have precedence, and if the hospital at any time becomes crowded, recent cases shall, for the time being, have precedence over those of a chronic character. The probate court of any county, or the judge thereof, upon applica- tion of any person, under oath, setting forth that any person, by reason of insanity, is unsafe to be at large, or is suffering under mental derange- ment, shall cause such person to be brought before said court, or judge, at a time appointed, and shall cause to appear at the same time one or more respectable physicians, who shall state, under oath, in writing, their opinion of the case. If the physician or physicians shall certify to the insanity or idiocy of the person, and it appears to the satisfaction of the court, or judge, that such certificate is true, said court, or judge, shall cause such insane or idiotic person to be taken to the Hospital for the Insane in Washington Territory ; provided, that such alleged insane per- son, or any person in his behalf, may demand a jury to decide upon the question of his insanity, and the court, or judge, shall discharge such person if the verdict of the jury is that he is sane. The probate court, or judge, shall also inquire as to the property of such insane person, and in case such person shall have sufficient means to bear such expense, two months' charges shall be paid in advance on his admission, and a like amount every two months thereafter so long as he remains in the hospital. If the relations or friends of such insane or idiotic person desire to take charge of him, the court, or judge, may so order, if sufficient bond is given that such insane or idiotic person shall be well and securely kept. If it be found by the court that the person so brought before it is of unsound mind, and incapable of managing his own affairs, and has property, the court shall appoint a guardian for the estate of such insane person. Paying patients, whose friends or whose property can pay their ex- penses, shall do so in accordance with the contract made with the trustees of the hospital. Whenever the court shall receive information that an insane person under guardianship has recovered his reason, it shall inquire into the facts, and, if it finds that such person is of sound mind, shall forthwith discharge him from care and custody. Any patient may be discharged from the hospital, when, in the judg- ment of the superintendent, it may be expedient. Whenever a patient not cured, or any indigent patient, shall be ordered discharged, he shall, if the superintendent thinks fit, be sent unattended to the county where he belongs ; but. if for any reason he is unfit to be sent alone, the superintendent shall so certify to the probate judge of said county, who shall order the sheriff to remove the patient to the county from which he came. No pauper shall be discharged from the hospital without suitable clothing, and such sum of money, not exceeding $10, aS the trustees deem necessary. There shall be no censorship exercised over the correspondence of the inmates of insane asylums, except as to the letters to them directed; but their other post-office rights shall be as free and unrestrained as are those of any other resident or citizen of this Territory, and be under the pro- tection of the same postal laws ; and every inmate shall be allowed to APPENDIX WEST VIRGINIA. 533 write one letter a week to any person he or she may choose. There shall be a post-office box in the asylum. In all asylum investigations, the testimony of any person offered as a witness, whether sane or insane, shall be competent, the court and jury being sole judges of its credibility. The district courts of the Territory shall have power to commit to the insane hospital any person Avho, having been arraigned for an indictable offence, shall be found by the jury to be insane at the time of such arraignment. When any person indicted for an offence shall on trial be acquitted by reason of insanity, the jury, in giving their verdict, shall so state, and thereupon, if the discharge or going at large of such insane person shall be considered by the court manifestly dangerous, the court may order him to be committed to the insane asylum, or may give him into the care of his friends, if they will give sufficient bonds that he will be well and securely kept. Otherwise he shall be discharged. WEST VIRGINIA. 1 Any justice who shall suspect any person in his county to be a lunatic, shall issue his warrant and have the person brought before him. He shall make inquiry whether such person is a lunatic, and for that purpose sum- mon a physician and other witnesses. He shall propound so many of fifteen prescribed questions as are applicable to the case, touching the history and condition of the patient. If the justice decide that the per- son is a lunatic and ought to be confined in the hospital, and ascertain that he is a citizen of the State, then, unless some person will give suffi- cient security to restrain and take proper care of such lunatic, the justice shall order him to be removed to the hospital. The interrogatories and their answers, together with a written statement by the justice of any facts relating to the insanity, shall be sent with the order to the hospital. The sheriff or other officer who is to execute the order, shall make 1 inquiry of the superintendent whether he can receive the lunatic into the hospital, and whether he will send for the patient or have the sheriff take him to the hospital. Until the patient can be received in the hospital, he shall be kept in the jail of the county. When such patient arrives at the hospital, the examining board, consisting of the medical superinten- dent and one or more directors, shall be assembled as soon as may be, and, if they concur in opinion with the justice, the patient shall be registered as an inmate upon proper security for payment of expenses. If they refuse to receive the lunatic, the officer in charge of him shall 1 Eevised Statutes of West Virginia, Annotated, 1879, Vol. I. pp. 440, 446, 447; Vol. II. pp. 673-680 Acts of West Virginia, 1881, p. 266; 1882, pp. 133-137; 1883, pp. 55, 56. 534 APPENDIX WEST VIRGINIA. confine him in the jail of the county in which he was examined until lawfully discharged or removed therefrom. If a lunatic is found to be a non-resident, he shall be returned to his friends or to the proper authorities of the State from which he came, and the Governor shall collect from that State, if possible, the money expended for such patient. No non-resident lunatic shall be received or retained as a pay patient in the hospital, except when there is a vacancy not applied for on behalf of any person residing in the State. Insane persons of the naval service of the United States, who may be sent to the hospital by the Secretary of the Navy, may be received and kept so long as there is room not wanted for citizens of the State. Idiots are not to be sent to or received into the hospital, but are to be taken charge of by their committees if they have any, if not, by the supervisors or any of them. Except in case of insane criminals, the board of the hospital, or the circuit court of any county, may deliver any lunatic confined in the hos- pital, or in the jail, to any friend who will give sufficient security to restrain and properly care for the lunatic; and where a lunatic, not a criminal, is deemed by the superintendent of the hospital both harmless and incurable, the board may deliver him without any bond to any friend who is willing, and, in the opinion of the board, able to take care of him. When any person who has given bond and taken charge of a lunatic wishes to be relieved of the care of him, he may deliver him to the sheriff of the county according to the condition of the bond. The sheriff shall confine such patient in the jail of his county until a vacancy shall occur in the hospital. When any person shall be confined in any jail as a lunatic, the jailer shall certify the fact to the circuit court of the county at the next term. The court shall cause such person to be examined by two disinterested persons, who shall, as soon as may be, report the result thereof. The court shall then make such provision for his maintenance and care as his situation may require. The court in whose jail any lunatic may be con- fined, shall, when practicable and proper, contract with some fit person for the care and maintenance of such lunatic out of jail, and make allow- ance therefor not exceeding what is authorized for a lunatic confined in jail. The circuit court shall, on application of any party interested, examine any person suspected of being insane, with a view to appointing a com- mittee. If a person be found to be insane by the justice before whom he may be examined, or in a court in which he may be charged with crime, the circuit court of the county of which he is an inhabitant shall appoint a committee of him. The committee of an insane person shall be entitled to the custody and control of his person when he resides in the State and is not confined in the hospital or jail. When any person, not a criminal, confined in the hospital or jail as a lunatic shall be restored to sanity, the board of directors, if such person be in the asylum, or, if confined in jail, the circuit or county court, or any justice of the county in which such person is confined, upon exarni- APPENDIX WISCONSIN. 535 nation of such person, if it be found proper to do so, shall discharge such person and give him a certificate thereof. When a person in jail, on a charge of having committed an indictable offence, is not indicted by reason of his insanity at the time of commit- ting the act and the grand jury certify this fact, the court may order him to be sent to the hospital for the insane of the State, or to be discharged. If a court in which a person is indicted for a criminal offence see reason- able ground to doubt his sanity, at the time of trial, it shall suspend the trial and impanel a jury to inquire into the insanity. If the jury find that he is then insane, they shall inquire further whether he was so at the time of the alleged offence. If they find that he was so at that time, the court may dismiss the prosecution and either discharge him or, to prevent his doing mischief, remand him to jail and order him to be removed thence to the hospital for the insane. If they find that he was not insane at the time of the alleged offence, but has since become so, the court shall commit him to jail, or order him to be confined in the hospital until he is so restored that he can be put upon his trial. AY lien a person tried for an offence is acquitted by the jury by reason of his being insane, the verdict shall state the fact, and thereupon the court may, if it deem him dangerous, order him to be committed to jail until he can be sent to the hospital for the insane. If, after conviction and before sentence of any person, the court see reasonable ground to doubt his sanity, it may impanel a jury to inquire into the fact as to his sanity, and sentence him or commit him to jail or to the hospital for the insane, according as the jury may find him to be sane or insane. When any person confined in the hospital and subject to be tried for crime, or convicted of crime and held for sentence, shall be restored to sanity, the board shall give notice thereof to the clerk of the court by whose order he was confined. Such clerk shall issue a precept requiring the prisoner to be brought from the hospital and committed to jail. When a prisoner is so brought to the jail, or when it is found by the verdict of another jury that a prisoner whose trial or sentence was suspended by reason of his being found to be insane, has been restored, if already convicted, he shall be sentenced, and, if not, the court shall proceed to try him as if no delay had occurred on account of his insanity. WISCONSIN. 1 The management of the insane asylums is in the hands of the State board of supervision of Wisconsin charitable, reformatory, and penal in- 1 Revised Statutes of Wisconsin, 1878, pp 69, 205-215, 462, 520, 661, 662, 973- 975, 1042, 1098, 1099, 1139, 1140. Laws of Wisconsin, 1880, pp. 121, 122, 299-302, 317; 1881, pp. 245. 246, 274, 275, 283-287, 376, 378-388; 1882, pp. 400, 914; 1883, Vol. I. pp. 24-28, 128. 129, 135-138. 536 APPENDIX WISCONSIN. stitutions, which acts as commissioners of lunacy, with power to investi- gate the question of the insanity and condition of any person committed or confined in any lunatic hospital or asylum, public or private, or re- strained of his liberty by reason of alleged insanity. The board shall take the proper legal steps for the discharge of any person so committed or restrained, if, in its opinion, such person is not insane, or can be cared for after such discharge without danger to others and with benefit to himself. Any letter, communication or complaint, addressed to such board, or to any member thereof, by any inmate or employe in any of said institutions, shall be forwarded as addressed, without being opened or interfered with. Patients shall be admitted to the hospitals for the insane from the several counties in the ratio of their population, but each county shall be entitled to at least two patients, if desired. No person idiotic from birth shall be admitted ; and no person shall be retained in either hospital after, by a fair trial, it shall have become reasonably certain that such person is incurably insane, if the room is wanted for cases of a more hopeful character. But no person in the hospitals committed as an insane criminal shall be discharged without an order of the court having jurisdiction over such person. Whenever any resident of this State, or any person found therein whose residence cannot be ascertained, shall be, or be supposed to be, insane, application may be made in his behalf by any respectable citizen to the judge of the county court, judge of the circuit court, or any judge of a court of record in and for the county in which the patient resides, or, in case his residence is unknown, the county in which he is found, for a judicial inquiry as to his mental condition, and for an order of com- mitment to some hospital or asylum for the insane. The application shall be in writing, and shall specify whether or not a trial by jury is desired by the applicant. The judge applied to shall appoint two disinterested physicians of good repute for medical skill and moral integrity to visit and examine the person alleged to be insane. Such physicians shall forthwith, by personal examination, satisfy them- selves as to the patient's condition and report to the judge. Such report shall cover twenty-nine prescribed points touching the history and con- dition of the patient. Upon the receipt of the physicians' report the judge may, if no demand has been made for a jury, make his order of commitment to the hospital or asylum of the district to which the county belongs, or, if not fully satisfied, may make further investigation of the case. At any stage of the proceedings, and before the actual confinement of the person, he, or any relative or friend acting in his behalf, shall have the right to demand that the question of sanity be tried by a jury. In case a trial by jury is demanded, the forms of procedure shall be the same as in trials by jury in justices' courts, and the trial shall be in the presence of the person supposed to be insane, and his counsel and imme- diate friends, and the medical witnesses. All other persons shall be ex- cluded. If the jury find the person sane, he shall be discharged. If they find him insane, and a fit person to be sent to a hospital for the insane, they shall so state. The physician's report or certificate shall be sent with the patient to APPENDIX WISCONSIN. 537 the hospital or asylum. All proceedings relating to the commitment of insane persons shall be filed with the county judge of the county in which the insane person resides, who is required to keep a record-book, in which all proceedings shall be recorded, and be open to inspection. Whenever, in the opinion of the judge applied to, the public safety requires it, he may order the sheriff forthwith to take and confine the supposed insane person in some place specified, until the further proceedings for his com- mitment can be had, or until the further order of the judge. Or if, after the receipt by the judge of the report of the examining physician, he deems it proper, he may order the sheriff then to take the alleged insane person into custody, and keep him in some place specified until the further order of the judge. When any respectable citizen has reason to question the propriety or justice of the confinement of any patient committed to any hospital or asylum, he may apply to any of the judges above mentioned of the county in which such person resides, asking for a rehearing and a further judi- cial inquiry as to the mental condition of such person. The proceedings, upon the rehearing, shall be substantially the same as upon the original commitment. If, upon such rehearing, the patient is found to be sane, an order shall be made that he be set at liberty. If it is determined that he is insane, no further action shall be taken upon the application. No person not deemed dangerous when at large shall be committed to any hospital or asylum for the insane solely on account of physical in- firmity or mental imbecility. If any relative or friend of a patient committed to any hospital desires to perform the duty of taking him to the hospital, and is competent to do so, the warrant of commitment may be delivered to and executed by him, instead of by the sheriff. Each patient sent to the hospital must be furnished with the amount of clothing prescribed, or he may be rejected by the superintendent. When a patient is discharged as cured, the superintendent shall furnish him with suitable clothing, and a sum of money not exceeding $20. If the relatives or friends of any patient shall ask the discharge of such patient before he has recovered from his insanity, the superintendent may, in his discretion, require a bond to be executed, conditioned for the safe keeping of such patient. Incurable and harmless patients shall be discharged whenever it is necessary to make room for recent or more hopeful cases, except in case of persons under the charge of, or conviction of, crime. When an order is made for the removal of a patient, the superinten- dent, except when friends are willing to receive the patient, shall notify the county judge of the county from which the patient was sent, and he shall issue his warrant, directing the sheriff to remove the patient to the poor-house or jail in the county whence he was taken. Patients in either of the hospitals found to be non-residents of the State shall, when prac- ticable, be transferred to the proper officers of their own State. The several courts of record in the State shall be authorized to commit, for safe keeping and treatment, to either hospital for the insane, any person who shall be under charge of, or convicted before such court of, any crime punishable by imprisonment in the State Prison and awaiting 538 APPENDIX WISCONSIN. hearing, trial, conviction, or sentence, on account of alleged insanity at the time of the commission of such crime, or at any time afterwards and prior to sentence. Whenever it is found by an examination duly made that such a patient is no longer insane, the judge of the court from which such person was sent, and the district attorney of the proper county, shall be notified, and it shall be the duty of such judge to make an order for the removal of such person to the common jail of the county from which such person was sent, to be detained in such jail until further dealt with according to law, or until discharged therefrom in pursuance of law. Whenever any person tried for any criminal offence is acquitted on the ground that he was insane at the time of the alleged offence, if he has recovered his sanity at the time of trial, he shall be discharged, but, if he is still insane, he shall be confined in one of the State hospitals for the insane, to be kept as other patients are kept and treated therein. When any person is indicted or informed against for any offence, if there is a probability that such accused person is at the time of trial in- sane and incapacitated to act for himself, the court shall, in a summary manner, make inquisition by a jury or otherwise, as it deems most proper. If it is thus found that such accused person is insane, his trial shall be postponed indefinitely, and the court shall thereupon order that he be confined in one of the State hospitals for the insane. Upon the recovery of such person, he shall be committed to the county jail of the county where the indictment or information is pending, or held to bail for his appearance at the next succeeding term of said court for trial of such offence. If the accused is found to be incurably insane, he shall be treated and disposed of as other cases of incurable insanity according to law. Whenever it shall appear to the satisfaction of the Governor by the representation of the warden and directors of the State Prison, and by examination, that any person confined therein has become insane during his imprisonment, and is still insane, he may make an order that such insane person be confined and treated in one of the State hospitals for the insane, and, upon his recovery, if before the expiration of his sentence, that he be returned to the State Prison. Insane criminals and persons acquitted of crime on the ground of in- sanity, may be transferred to the Milwaukee County Asylum for the In- sane as well as to the State asylums. Whenever it is made to appear to a county judge, by a petition of a majority of the supervisors of any town, of the common council of any city, or of the board of trustees of any village, that the public safety re- quires the close custody of any poor insane person of such town, city, or village, the judge shall direct the sheriff forthwith to take and confine such insane person in some proper place specified. Such insane person, when so confined, shall be subject to the directions of the said judge, and shall receive such care, attention, and treatment as such judge shall deem proper and necessary. Whenever there is not room in the State asylums for the insane of any county, such county may establish a county insane asylum. Upon the completion of such asylum, all inmates of the State institutions for the insane committed from, or belonging to, such county, held as chronic or incurable, and all insane inmates of the poor-house of such county, and APPENDIX WYOMING. 589 all other persons belonging to said county and duly adjudged to be in- sane, may be transferred to said county asylum : provided, however, that when any patient committed to the county asylum is found to belong to the class defined as acute insane, and to require permanent and special treatment for the purpose of cure, such person may be transferred to the State hospitals for the insane. When there is any room in any such county insane asylum for more than the patients of the county, patients from any other county may be received and cared for. A portion of the expense of erecting such county insane asylums, and of keeping patients therein, is paid by the State upon certain conditions and stipulations. Whenever any county has not made suitable provisions for the proper and humane care of its chronic or its acute insane, the board of charities or reform may direct the removal of either class of said insane to any county asylum, or to any other county possessing suitable accommoda- tions therefor for care or medical treatment, as the circumstances seem to require. Corporations may be formed for maintaining private insane asylums for the care and treatment of insane and feeble-minded persons. Any insane or feeble-minded person may, upon the written request of the guardian, or any friend of such person, be committed to any such private hospital or asylum in the same manner that insane persons are committed to the State Hospital for the Insane. Insane or feeble-minded persons may voluntarily place themselves under the care and treatment of any such hospital, asylum, or institution. All such private asylums are subject to substantially the same rules and provisions for supervision and visitation as the State hospitals for the insane. Any person neglecting or abusing an inmate of an asylum for the in- sane shall be liable to a fine of $200, or one year's imprisonment. WYOMING. 1 (TERRITORY.) There is no insane asylum in Wyoming. Patients are sent to the Iowa Hospital for the Insane, and elsewhere. Each county has the responsibility of caring for, and paying the expenses of, its pauper insane. If information in writing be given to the probate judge that any per- son in the county is an idiot, lunatic, or person of unsound mind, and praying that an inquiry thereinto be had, the court, if satisfied that there is good cause for the exercise of its jurisdiction, shall cause the facts to be inquired into by a jury. If the court is not in session, a special term 1 The Compiled Laws of Wyoming, 1876, pp. 35, 161, 162, 248, 249, 280, 295, 472- 476. Session Laws of Wyoming, 1882, pp. 132, 133. 540 APPENDIX WYOMING. may be called for the purpose of holding an inquiry. The probate court may cause the person alleged to be of unsound mind to be brought before it, in its discretion, in the course of the proceedings. Whenever any judge of the probate court, justice of the peace, sheriff, coroner, or con- stable shall discover any person, resident of his county, to be of unsound mind, it shall be his duty to make application to the probate court, and thereupon like proceedings shall be had as in the case of information by unofficial persons. If it be found by the jury that the person inquired about is of unsound mind, and incapable of managing his affairs, the court shall appoint a guardian of the person and estate of such person. The court may, if just cause appears, at any time during the term at which an inquisition is had, set the same aside, and cause a new jury to be impanelled to inquire into the facts ; but when two juries concur in any case, the verdict shall not be set aside. Every guardian of a person of unsound mind shall give a bond condi- tioned that he will take due and proper care of such insane person and of his property, and will faithfully do and perform all things enjoined upon him by the order of the court. Every such guardian shall take charge of the person committed to his charge, and provide for his support and maintenance. If any person by lunacy or otherwise shall be furiously mad, or so far disordered in his mind as to endanger his own person, or the person or property of others, it shall be the duty of his guardian, or other person under whose care he may be, to confine him in some suitable place until the next sitting of the probate court of the county, which shall make such order for the restraint, support, and safe keeping of such person as the circumstances may require. If any such person furiously mad shall not be confined by the person having charge of him, or there be no person having such charge, any judge of a court of record, or any two justices of the peace, may cause such insane person to be apprehended, and may employ any person to confine him in some suitable place until the probate court shall make further order therein. If any person shall allege in writing, verified by oath, that any person declared to be of unsound mind has been restored to his right mind, the court by which the proceedings were had shall cause the facts to be in- quired of by a jury. If it shall be found that such person has been restored to his right mind, he shall be discharged from care and custody. Any person that becomes lunatic or insane after the commission of a crime or misdemeanor ought not to be tried for the offence during the continuance of the lunacy or insanity. If, after verdict of guilty, and before judgment pronounced, such person becomes lunatic or insane, no judgment shall be given while such lunacy or insanity continues. If, after judgment and before execution, such person becomes insane, then, in case the punishment be capital, the execution thereof shall be stayed until the recovery of such person from the insanity. In all these cases, it shall be the duty of the court to impanel a jury to try the question whether the accused be at the time of impanelling insane or not. If any convict sentenced to the punishment of death shall appear to be insane, the sheriff shall give notice to a judge of the district court of APPENDIX UNITED STATES. 541 the judicial district, and shall summon a jury of twelve men to inquire into such insanity, at a time and place fixed by the judge, and shall give notice to the prosecuting attorney. If it be found that the convict is insane, the judge shall suspend the execution of the convict until such time a the Governor shall direct his execution. The Governor shall be notified of the proceedings and the finding, and, as soon as he is con- vinced that the convict has become of sound mind, he may issue a warrant appointing a time for his execution. UNITED STATES. 1 (DISTRICT OF COLUMBIA.) The chief executive officer of the Government Hospital for the Insane of the Army and Navy of the United States and of the District of Columbia is the superintendent, appointed by the Secretary of the Interior. He shall, upon the order of the Secretary of War, the Secretary of the Navy, and the Secretary of the Treasury respectively, receive and keep in custody, until they are cured or removed by the same authority which ordered their reception : (1) Insane persons belonging to the army, navy, marine corps, and revenue cutter service. (2) Civilians employed in the quartermaster's and subsistence departments of the army, who may be, or may become, insane while in such employment. (3) Men who while in the service of the United States, in the army, navy, or marine corps, have been admitted to the hospital and have been dis- charged on the supposition that they were cured, and who have within three years after such discharge become again insane from causes exist- ing at the time of such discharge, and have no adequate means of support. (4) Indigent insane persons who have been in either of the said services and have been discharged therefrom on account of disability arising from such insanity. (5) Indigent insane persons who have become insane within three years after their discharge from such service from causes which arose during and were produced by such service. Also persons in the marine-hospital service becoming insane may be admitted to the Government Hospital for the Insane upon the order of the Secretary of the Treasury. Any inmate of the National Home for Disabled Volunteer Soldiers who is or may become insane, shall upon an order of the President of the Board of Managers of the National Home be admitted to said insane hospital and treated therein. The Secretary of the Navy may cause persons in the naval service, or marine corps, who become insane while in the service, to be placed in such hos- pital for the insane as in his opinion will be most convenient and 1 Revised Statutes of the United States, 1873-1874, pp. 263, 945-948. Supplement to the Revised Statutes of the United States, Vol. I., 1874-1881, pp. 104, 191, 289, 461, 559. United States Statutes, 1881-1882, pp. 329, 330. 542 APPENDIX UNITED STATES. best calculated to effect a cure ; and he is not restricted to the Govern- ment Hospital for the Insane. All indigent insane persons, residents in the District of Columbia at the time they became insane, shall be entitled to the benefits of the hos- pital for the insane, and shall be admitted on the order of the executive authority of the District. The Secretary of the Interior may grant an order for admission into the hospital, when application is made in writing by a member of the board of visitors, accompanied by the certificate of a judge of the supreme court for the District of Columbia, or of any justice of the peace of the District. It must appear by this certificate that two respectable physicians, residents of the District, appeared before said judge or justice and deposed in writing that they knew the person alleged to be insane; that, from personal examination, they believed Him to be insane and a fit subject for treatment in the hospital; and that he was a resident of the District when seized with the mental disorder then afflict- ing him. It must further appear by said certificate that two respectable householders, residents of the District, appeared before said judge or justice and deposed in writing that they knew the person alleged to be insane, and from personal examination believed such insane person unable to support himself or himself and family, if he have one, and unable to pay his board in the hospital. The affidavits of said physicians and householders shall accompany the certificate of the judge or justice. The application must be made within five days after the date of the affidavits, and it must appear that the visitor applying has examined the affidavits and certificate. It shall be the duty of such visitor to withhold his application if he has reason to doubt the indigence of the insane person. The order of the Secretary of the Interior being granted, any police officer or constable may assist in carrying such insane person to the hospital. If the patient is found to have some property, he may be required to pay such part of his expenses in the hospital as may be just and reason- able. Any indigent insane person who did not reside in the District at the time he became insane, may be received into the hospital in like manner, to stay temporarily, until it can be ascertained who his friends are, or whence he came. Whenever there are vacancies, private patients from the District may be received, the rate of board to be determined by the visitors. The pay patients may be received on the certificate of two respectable physicians of the District, stating that they have personally examined the patient, and believe him to be insane, and a fit subject for treatment in the hos- pital. There must be also a written request for the admission from the nearest relatives, legal guardian, or friend of the patient. The request must be made within five days of the date of the certificate of insanity. If any person will give bond, with sufficient security, to restrain and take care of any pay, or any indigent, insane person, not charged with a breach of the peace, whether in the hospital or not, the supreme court of the District, or any judge thereof, in vacation, may deliver the patient to him, to be kept until restored to sanity. APPENDIX UNITED STATES. 543 If any person charged with crime be found in the court before which he is so charged to be an insane person, such court shall certify the same to the Secretary of the Interior, who may order such person to be con- fined in the Hospital for the Insane. Any person becoming insane during the continuance of his sentence in the United States Penitentiary shall have the same privilege of treat- ment in the hospital during the continuance of his mental disorder as is granted above to persons who escape the consequences of criminal acts by reason of insanity. If it be the opinion both of the physician to the penitentiary and the superintendent of the hospital that such insane con- vict is so depraved and furious in his character as to render his custody in the hospital insecure, and his example pernicious, he shall not be received. When any person, confined in the Hospital for the Insane, charged with crime, and subject to be tried therefor, or convicted of crime, and undergoing sentence therefor, shall be restored to sanity, the superinten- dent of the hospital shall give notice to the judge of the criminal court, and deliver him to the court, in obedience to the proper precept. No insane person, not charged with any breach of the peace, shall be confined in the United States Jail, in the District of Columbia. Upon the application of the Attorney-General, the Secretary of the Interior shall transfer to the Government Hospital for the Insane, in the District of Columbia, all persons who, having been charged with offences against the United States, are in the actual custody of its officers, and all persons who have been or shall be convicted of any offence in a court of the United States, and are imprisoned in any State prison or peniten- tiary of any State or Territory, and who, during their term of imprison- ment, have or shall become insane. In all cases where there shall not be accommodation for such insane convicts in the Insane Asylum of the District of Columbia, or if, for other reasons, the Attorney- General is of opinion that such insane person should be placed at a State insane asylum, rather than at said District Asylum, then the Attorney-General shall have power, in his discretion, to contract with any State insane or lunatic asylum within the State in which such convict is imprisoned for his care and custody while he remains insane. Whenever such insane convict shall be restored to sanity, he shall be returned to the prison or peniten- tiary from which the transfer was made, provided the term of imprison- ment shall not have expired. The questions of sanity in all such cases shall be determined in accord- ance with the rules and regulations of existing laws, State or national, on the subject, applicable to the prison, penitentiary, or asylum where such convict shall be confined. INDEX. ACUTE mania, 136 Adolescence, insanity of, 379 mortality in, 387 progress in, 386 recovery in, signs of, in, 382 symptoms of, 379 treatment of, 383 psychology of, 375 Affections cooled by insanity, 140 Affective insanity, 231 Ague, insanity from, 417 Alabama, laws respecting insane, 439 Alcohol a cause of insanity, 312 Alcoholic degeneration, 317 insanity, 312 Alcoholism, acute, 313 chronic, 315 Alimentation psychologically considered, 39 Alternating insanity, 170 Alternation in insanity, 170 Amenorrhceal insanity, 336 Amentia, 43, 204 Anaemia in insanity of lactation, 360 Anwmic brain, 326, 360 insanity, 411 Animal food, its effects on neurotic chil- dren, 167, 384 impulse, 244 Aphasia, case of, 278 Appointments in lunacy, 36 Arizona, laws respecting insane, 440 Arkansas, laws respecting insane, 441 Arteries, lesions of, in brain syphilis (Plate VIII. Fig. 1), 305 Arteritis, syphilitic, 302, 305, 306 Asthma, insanity of, 416 "DAILLAKGEK first described circular X) insanity, 171 Baths, hot, in mania, 145, 155 in melancholia, 120, 211 Turkish, in melancholia, 120, 211 Belladonna as a sleep producer, 169 Benedick on the brains of criminals, 232 Bird, G., on oxaluria, 415 Blistering in mania, 154 Boils in mania, 154 Brain, anajmic, 326 Brain, functions of, as related to mental diseases, 46-49 pathological disorders of, 45 Briglat's disease, insanity in, 414 Bromides as hypnotics, 168 in circular insanity, 187 in epilepsy, 295, 297 in mania, 146 Brown, J. J., on a new lesion in acute mania (Plate VII. Fig. 2; Plate VIII. Figs. 1, 2, 5), 92 on lesions in senile dementia, 408 on syphilitic arteritis, 305 Bucknill and Tuke on post-febrile in- sanity, 417 CADELL, Dr., his case of svphilitic in- sanity, 302 California, laws respecting insane, 442 Campbell, J. A , cases of melancholia, 74 413 Camphor as a sleep producer, 147, 169 Cannabis Indica in alternating insanity 187 in mania, 146 in melancholia, 94 Cat, maternal instinct in, 235 Certificates for Curator Bonis, 427 for treatment in private houses, 424 of lunacy, 35, 424 of sanity, 427 Chancery, affidavits for, 427 Children, insanity in sensitive, 55, 121 Chloral as a sleep producer, 168 insanity from use of, 318 use and dangers of, in mania, 146 Chorea, delirium of, 324 its connection with rheumatism, 319 Choreic insanity in early youth, 324 its epidemic forms, 325 prognosis in, 324 treatment of, 325 Circular insanity, 170 causes of, 184 duration of, 174-177 frequency of, 183 its nature, 171 pathology of, 187 symptoms of, 180 35 546 INDEX. Circular insanity, termination of, 184 treatment of, 185 Clark, Campbell, his case of hydrocephalic idiocy, 215 Classification of insanity, 44, 45 Climacteric insanity, 388 pathological appearances in, 393 prognosis in, 393 statistics of, 393 suicidal longings in, 389 symptoms of, 389 Climacteric in man, 391 in woman, 389 psychology of, 388 Colorado, laws respecting insane, 444 Competitive examinations, mischief from, 121 Congestion of brain in acute mania (Plate III.), 156 Conium in acute mania, 147 Connecticut, laws respecting insane, 445 Connubial affection altered in climacteric insanity, 388 Conscience a brain quality, 256 Consciousness lost in epilepsy, 295 in mania, 138 in stupor, 219 Convolutions, supply of blood to (Plate VII. Fig. 5), 48 their structure and function, 46 Convulsive melancholia, 98 Cretinism, 216 Croom, Dr. Halliday, on perversions of appetites, during menstruation, 336 Curator Bonis, appointment of, 427 Cyanosis, insanity of, 416 DAKOTA, laws respecting insane, 448 Deaf-mutism, an hereditary neurosis, 216 Decoration, insane, 190 Delaware, laws respecting insane, 450 Delirium in young children, 421 Delirium tremens, 50, 313 De lunatico inquirendo, 427 Delusions, insane, defined, 189 should be tested, 50 their legal importance, 201 of melancholia, in idiots, 188 list of, 88 sane and insane, 88 Delusional mania, 157 melancholia, 72 Dementia, alcoholic, 316 its varieties, 206 organic, 206, 276 primary, 212 prognosis in, 209 secondary, 206 senile, 395 Demonomania, 84 Deprivation, idiocy by, 216 insanity by, 418 Destructive impulse, 248 Diabetic insanity, 411 Diabolic possession, superstition of, 84 Diathesis, the insane, 257 doctrines of, 39 Diet (see Animal Food) in circular in- sanity, 185 in melancholia, 117 Dietetic management of the nisus genera- tivus, 346 Dipsomania, 250 Dipsomaniacs, laws respecting, 447 District of Columbia, laws respecting in- sane, 541 Douse on prevalence of syphilis, 301 Drunkards, laws respecting, 447, 462 Duncan, Dr. Mathews, on fecundity, 375 EDUCATION of girls, 369 j of neurotic children, 433 Eggs in the treatment of acute mania, 148 Electricity, delusions of being tortured by, 83 in detecting feigned insanity, 431 in stupor, 211, 224 Enfeeblement, morbid, 204 Epileptic insanity, 286 counter-irritations in, 296 hallucinations in, 293 pathology of, 292, 295 prevalence of, 297 religious emotionalism in, 288. 289 suicidal impulses in, 293 treatment of, 295 suicide of an, 294 Epileptics, criminal, 288 Epileptiform convulsions in general paral- ysis, 268 impulse, 243 melancholia, 92 Epilepsy compatible with sanity, 286 masked, 287 Epithelial granulations in ventricles (Plate VII. Fig. 3), 274 Ergot in melancholic stupor, 224 Erotomania, 236 Esquirol's classification, 42 Exaltation, physiological, 123 Examining patients, rules for, 49 Excited melancholia, 90 T7ALKET on circular insanity, 171 JL Fattening in insanity of adolescence, 383 Fears, morbid, 64, 199 Feeding, forcible, 107 Ferrier on brain localization, 82 Flesh meat. See Animal Food. Florida, laws respecting insane, 451 Folie a double forme, 170 circulaire, 170 commencement of, 184 pathology of, 187 termination of, 184 treatment of, 185 INDEX. 547 Folie raisonnante, 135, 171 Friends, Society of, insanity in, 381 GENERAL paralysis, definition of, 260 lj etiology and distribution, 269, 276 its nature, 275 pathology of, 272 prevalence and ages (Plate VI.), 276 stages of, 260 varieties, pathological, 265 symptomatological, 267 Georgia, laws respecting insane, 452 Gouty insanity, prognosis of, 325 termination in, 326 TJpEMATOMA auris, 97, 265, 379 IT Hallucination, a, defined, 139 Hemiplegia, 277 alternating, 92 Hereditary tendency, 39 of melancholic diathesis, 115 Home treatment expensive, 51 its advantages, 52 Homicidal impulse, 244 mania, 162 melancholia, 104 Hygiene in neurotic children, 432 Hyoscyamine in mania, 146 Hyoscyamus as a hypnotic, 169 Hyperkinesia, 231 Hypnotics in insanity, 145 Hypochondria^ 55 Hypochondriacal melancholia, 67 Hysterical insanity, 340 statistics of, 341 Hystero-epilepsy, 340 TDAHO, laws respecting insane, 454 L Idiocy, by deprivation, 217 definition of, 212 eclampsic, 214 epileptic, 214 genetous, 213 hydrocephalic, 215 inflammatory, 215 microcephalic, 215 paralytic, 214 traumatic, 215, 300 Illegitimacy a cause of puerperal insanity, 356 Illinois, laws respecting insane, 455 Illusion, an, defined, 139 Imbecility, 212 congenital, 212 Impulse, animal, 231 destructive, 249 homicidal, 231 insane, 231 suicidal, 231 uncontrollable, 231 Impulses, morbid, 237 Impulsive insanity, 231 Impulsive insanity, a remarkable case of, 238 Incoherence in mania (Plate II.), 138, 139 Indecision, morbid, 60 Indiana, laws respecting insane, 457 Inebriate apylums, 447 Inhibitory insanity, 231 power, defective, 231 Inglis, T., on hystero-epilepsy with in- sanity, 340 Insane impulse, 231 Insanity, alcoholic, 312 amenorrhreal, 336 anaemic, 411 by deprivation, 418 choreic, 319 circular, 170 climacteric, 388 diabetic, 411 epileptic, 286 feigned, 431 gouty, 325 hysterical. 340 inhibitory, 285 meta^tatic, 416 moral, 255 of adolescence, 397 of asthma, 416 of Bright's disease, 414 of cardiac disease, 416 of cyanosis, 416 of exophthalmic goitre, 419 of lactation, 359 of lead-poisoning, 421 of masturbation, 342 of myxcedema, 419 of oxaluria, 415 of phosphaturia, 415 of pregnancy, 363 of puberty, 368 ovarian, 336 paralytic, 276 phthisical, 326 post-connubial, 421 post-febrile, 416 puerperal, 349 rheumatic, 319 senile, 395 syphilitic, 301 traumatic, 298 Iowa, laws respecting insane, 459 Ireland, W. W.., on idiocy, 212 Irritability defined, 234 JACKSON, J. HUGHLINGS, on epi- ?J leptic insanity, 287 on syphilitic insanity, 301 KANSAS, laws respecting insane, 462 Katatonia, 182 Kentucky, laws respecting insane, 464 Kleptomania, 45, 236, 254 548 INDEX. T ACTATIOX, insanity of, 359 Jj prognosis in, 363 statistics of, 363 symptoms of, 360 treatment of, 361 Lawlessness, organic, 232 Laycock, T., on general paralysis, 267 on organic memory, 138 Laziness often a disease, 64 Lead-poisoning, insanity of, 421 Legal views about insanity, 428 Louisiana, laws respecting insane, 466 Lunatics, their number, 35 Lycanthropia, 236 MACLAREN, J., his case of impulsive insanity, 238 Maine, laws respecting insane, 467 Major H., on senile brains (Plate VIII. Fig 4), 408 Mania a potu, 317 Mania, 43, 123 acute, 136 caused by a new lesion (Plate VIII. Fig. 5), 156 chronic, 157 definition of, 124 delusional, 157 delusions in, 165 diet in, 144 ephemeral (transitoria), 161 first stage of, 137 homicidal, 162 in children, 123 periodic, 170 prevalence of (Plate VI.), 167 prognosis of, 165 prophylaxis in, 167 recurrent, 170 second stage of, 137 simple, 125 termination of, 166 treatment of acute, 144, 211 Marriage in circular insanity, 185 in masturbational insanity, 347 with neurotic persons, 431 Maryland, laws respecting insane, 470 Massachusetts, laws respecting insane, 471 Massage, 63 Masturbation, insanity of, 342 bodily signs in, 343 bromides in, 347 statistics of, 347 treatment of, 346 self-learned, 345 Maudsley, H., 34 on phthisical insanity, 328 on the insane diathesis, 257 Mechanical restraint in mania, 142 Medical psychology defined, 34 Medico-legal duties of medical men in mental diseases, 424 Megalomania, 113, 190 Melancholia, bodily symptoms of, 114 Melancholia, causation of, 115 convulsive, 98 definition and nature, 56 delusional, 72 delusions in, 88 epileptiform, 92 excited, 90 hereditary predisposition in, 115 homicidal, 104 hypochondriacal, 67 inception of, 113 in children, 421 lesions in brain in (Plate VII. Fig. 1), 76, 81, 82, 102 organic, 100 prevalence and ages (Plate VI.), 114 prognosis of, 67, 115 prophylaxis of, 121 religious, 84 resistive, 94 simple, 57 suicidal, 104 termination of, 116 treatment of, 117, 211 Melancholic diathesis, 55 persons, 54 Melancholy v. malancholia, 56 Melancholy, hereditary, 55 Memorv in acute mania, 138 morbid, 138 Menstruation in acute mania, 153 insanity from suspended, 338 psychology of, 336 Mental conditions liable to be mistaken for insanity, 50 Metastatic insanity, 416 Michigan, laws respecting insane, 475 Mickle on the use of opium, 120 Milk in acute mania, 144 in adolescent insanity, 383 in melancholia, 117 Minnesota, laws respecting insane. 477 Mississippi, laws respecting insane, 479 Missouri, laws respecting insane, 480 Monomania (mono-psychosis), 43, 44, 188 diagnosis of, 200 of grandeur, 190 of suspicion, 196 of unseen agency, 193 origin of, 201 prognosis of, 202 prophylaxis of, 202 treatment of, 202 Montana, laws respecting insane, 483 Moral insanity, 255 Pritchard's, 171 Moreau de Tours on human degeneration, 312 Morel on delirium in phthisis, 327 on human degeneration, 312 Morselli on suicide, 106 Mouth-openers, 107 Myxcedema, 419 INDEX. 549 VTARCOTICS in mania, 146 1M in melancholia, 120 Nebraska, laws respecting insane, 485 Necrophilism, 236 Neuralgia analogous to melancholia, 42 Neurasthenia, 63 Neurosis, insane, 45 spasmodic, 45 Nevada, laws respecting insane, 488 New Hampshire, laws respecting insane, 489 Newington, Hayes, on alternating hemi- ' plegia, 92 on anergic stupor, 219 on mania a potu, 317 on syphilis as a cause of insanity, 310 on syphilomatous insanity, 304 New Jersey, laws respecting insane, 491 New Mexico, laws respecting insane, 494 New York, laws respecting insane, 495 Nitrite of amyl in mania, 146 North Carolina, laws respecting insane, 502 ABSTINACY, morbid, in melancholia, U 94 Ohio, laws respecting insane, 503 Old maid's insanity, 339 Opium useful against sleeplessness, 169 useless in mania, 146 useless in melancholia, 120 Oregon, laws respecting insane, 507 Organic dementia, 276 insanity, 275 melancholia, 100 Oxaluria, insanity of, 415 period of, 415 PARALYSIS. See General Paralysis. L Paralysis of energy, 63 of feeling, 63 Paralytic insanity, 276 analogies, 278 causes, 277 congestive and epileptiform at- tacks in, 282 pathology of, 285 recovery in, 281 statistics of, 285 symptoms of, 278 Pennsylvania, laws respecting insane, 508 Periodicity in mental diseases, 170 Phosphates in melancholia, 117 Phosphaturia, insanity of, 415 Phosphorus in mental depression, 117 Pkthisica spes, 334 Phthisical insanity, 326 pathology of, 331, 332 prognosis in, 334 statistics of, 327 symptoms of, 328 Phthisis common among the insane, 327 mental condition in, 329 Pia mater adherent in general paralvsis (Plate I.), 273 Planomania, 236 Podagrous insanity. See Gouty Insanity. Post-connubial insanity, 421 Post-febrile insanity, 416 Pregnancy, insanity of, 363 character of, 364 prognosis in, 366 statistics of, 367 suicidal tendency in, 366, 367 psychology of, 363 Pritchard's moral insanity, 126 Prout on oxaluria, 415 Psychalgia, 43 Psychlampsia, 43, 123 Psychocoma, 44, 217 Psychokinesia, 44, 231 general, 238 Psychology, medical, 34 Psychoneurosis, 44 Psychoparesis, 43, 204 Psychorhvthm, 44, 170 Puberty, Insanity of, 368, 373 period of, 368 Puerperal insanity, definition of, 349 frequency of, 355 heredity in, 356 pathology of, 355 prognosis in, 358 statistics of, 355 symptoms of, 350 Pyromania, 236 QUININE in melancholia, 117, 211, 354 T) AYNER on the insanity of lead-poison- H ing, 421 Reasoning insanity, 171 Relapses in insanity, 170 Religious melancholia, 84 Reproduction psychologically considered, 40, 371 Resistive melancholia, 94 Responsibility, legal, 233 Restraint in mania, 142 Rheumatic insanity, 319 Rhode Island, laws respecting insane, 515 Robertson, A., on the insanity of lead- poisoning, 421 O ATYRIASIS, 236 U Savage on the insanity of lead-poison- ing, 421 Self-control, sane lack of, 231 Senile insanity, 395 hallucinations of hearing in, 404 management of, 409 motor restlessness in, 397 pathology of, 406 prognosis in, 405 statistics of, 396 550 INDEX. Senile insanity, treatment of, 409 Senility, psychology of, 395 Sensibility diminished in mania, 142 Septic inflammations in mania, 154 Septicaemia and puerperal insanity, 355 Shower-baths, 211 Skae, C. H., cases of trephining, 299 Skae, D., his classification, 45 Smith, Willie, the homicide, 163 Somnambulism, 421 South Carolina, laws respecting insane, 518 Stewart, H. G., on delusional syphilitic insanity, 303 on monomania of unseen agency, 194 Stewart, T. G., on insanity from Bright's disease, 414 Stimulants in melancholia, 118 Strychnine in mania, 147 in melancholia, 117 in threatened dementia, 211 Study of mental diseases, 34-42 Stupor, anergic, 226 causation of, 230 definition of, 217 epileptic, 230 melancholic, 220 paralytic, 230 prognosis in, 230 secondary, 229 treatment of, 230 varieties of, 219 Suicidal impulse, 247 frequency of, 110 melancholia, 104 Suicide, a determined, 108 case of, 217 in an epileptic, 294 letter of a, 108 modes of committing, 105-107 Sunstroke a cause of insanity, 298 Suspicion, monomania of, 196 Sydenham on insanity from ague, 417 Symptomatological classification, 44 Syphilis, its prevalence, 301 Syphilitic insanity, 302 cephalalgia in, 309 delusional, 303 pathology of, 304, 308, 311 prognosis in, 311 secondary, 302 syphilomatous, 304, 307 treatment of, 309 vascular, 304 TEMPERAMENTS, doctrine of, 39 JL melancholic, 55 sanguine, 123 Temperature, in children, 123 in insanity, 49 in mania, 128, 141 in puerperal insanity, 356 Tennessee, laws respecting insane, 520 Tests of insanity made by lawyers, 428 Texas, laws respecting insane, 522 Traumatic idiocy, 300 insanity, 298 prevalence of, 300 trephining in, 299 Tuke, D. Hack, on stupor, 218 Tuke, J. Batty, his statistics of puerperal insanity, 359 on lactational insanity, 362 Tumors of brain and insanity, -281 Twins, with hereditary neurosis, 168 TTNCONTROLLABLE impulse, 231 U United States, laws respecting in- sane, 541 Utah, laws respecting insane, 524 YASO-MOTOR spasm, 102 Vermont, laws respecting insane, 526 Verriicktheit primare, 135, 259 Visceral melancholia, 74 pathology of (Plate VII. Fig. 1), 82 Volitional insanity, 231 TI/'ASHINGTON, laws respecting in- TT sane, 531 West Virginia, laws respecting insane, 533 Wilkes on insanity from Bright's disease, 414 on svphilitic affections, 301 Will-making, 429 Wisconsin, laws respecting insane, 535 Wyoming, laws respecting insane, 539 YTELLOWLEES. D., his case of homi- JL cidal mania, 163 his case of somnambulism, 422 A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. With an Appendix on the Researches of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of Phthisis. By AUSTIN FLINT, M.D., Professor of the Principles and Practice of Medicine and of Clinical Medicine in Bellevue Hospital Medical College, N. Y. Fifth edition, revised and largely rewritten. In one large and closely printed octavo volume of 1160 pages. Cloth, $5.50; leather, $6.50; very handsome half Russia, raised bands, $7.00. Just Ready. considerable number of men use it alone in the study of pure medicine; and we can say of it that it is in every way adapted to serve, not only as a complete guide, but also as an ample instructor in the science and practice of medicine. The style of Dr. Flint is always polished and engaging. The work abounds in per- spicuous explanation, and is a most valuable text-book of medicine London Medical Neivs. A well-known writer and lecturer on medicine recently expressed an opinion in the highest degree compli- mentary of the admirable treatise of Dr. Flint, and in eulogizing it, he described it accurately as " readable and reliable." No text-book is more calculated to enchain the interest of the student, and none better classifies the multitudinous subjects included in it. It has already so far won its way in England, that no in- The Pathology and Treatment of Venereal Diseases, including the results of recent investigations upon the subject. By F. J. BUMSTEAD, M.D., LL. D., Late Professor of Venereal Diseases at the College of Physicians and Surgeons, New York, etc., and R. W. TAYLOR, A.M., M.D., Surgeon to Charity Hospital, New York, Professor of Venereal and Skin Diseases in the University of Vermont, President of the American Dermatological Association. Fifth edition, revised and largely rewritten by Dr. Taylor. In one large and handsome octavo volume of 898 pages, with 139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75 ; leather, $5.75 ; very handsome "half Russia, $6.25. For more than a score of years this work has been accepted as a standard, and pride has been felt in it as reflecting the utmost credit upon American medicine. Dr. Taylor's rare power of clinical observation, his talent for terse and graphic description stand out with undiminished prominence in this edition. The colored illustrations are admirable in execution, and well cal- culated to aid in the elucidation of the text. The work as it now stands, is beyond peradventure destined to maintain, for many years to come, its position as one of the foremost medical books in any language. Nevj York Medical Journal , March 29, 1884. A System Of Surgery: Pathological, Diagnostic, Therapeutic and Opera- tive. By S. D. GROSS, M.D., LL.D., D.C.L. Oxon., LL. D. Cantab., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, $15.00 ; half Russia, raised bands, $ 16.00. We regard Gross' System of Surgery not only as a singularly rich storehouse of scientific information, but as marking an epoch in the literary history ot surgery. The present edition has received the most caretul revision at the hands of the eminent author himself, assisted in various instances by able specialists in various branches. All departments of the vast and ever in- creasing literature of the science have been drawn upon for their most recent expressions. The late advances made in surgical practice have been carefully noted. In every respect the work reflects lasting credit on American medical literature. Medical and Surgical Reporter, Nov. n, 1882. A Practical Treatise on Fractures. By LEWIS A. STIMSON, B.A., M.D., Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator to Bellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc. In one very handsome octavo volume of 598 pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75. The author gives in clear language all that the prac- tical surgeon need know of the science of fractures, their etiology, symptoms, process of unijn and treat- ment, according to the latest developments. A thorough explanation of the pathological anatomy and a careful description of the various methods of procedure make the book full of value for every practitioner. The diction is simple, clear and vivid. Wherever desirable, brief clinical histories are introduced, which, being skilfully chosen to illustrate particular points, attest the rich experience of the author. The numerous beauti- fully executed illustrations form an especial attraction of the book. Centralblatt fur Chirurgie, May 19, The Topographical Anatomy of the Brain. By JOHN c. DALTON. M.D., Professor of Physiology in the College of Physicians and Surgeons, New York. In one very handsome quarto volume of about 200 pages of descriptive text, with forty-nine life-size photographic plates of Brain Sections, and a like number of outline explanatory plates, as well as many carefully executed woodcuts through the text. Shortly. HENRY C. LEAS SON & CO., PHILADELPHIA. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. By DANIEL HACK TUKE, M.D., Joint Author of the Manual of Psychological Medicine, etc. New edition. Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with two colored plates. Cloth, $3.00. Just Ready. In all medicine that pertains to psychological subjects ; tion We heartily wish this volume could find a place no one occupies a more exalted position than the well- in every physician's library, for here may be found a known author of this volume. His investigations in physiological explanation of many perplexing phe- regard to mental phenomena always command atten- . nomena. Cincinnati Lancet and Clinic, Mar. 29, 1884. Preventive Medicine. By B. w. RICHARDSON, M.A., M. D., LL. D., F.R.S., F.S.A., Fellow of the Royal College of Physicians, London. In one octavo volume of 729 pages. Cloth, $4.00; leather, $5.00; very handsome half Russia, raised bands, $5.50. Just Ready. The volume before us is a classical production, com- of its kind thathasever been published. It is scientific, prehensive in scope, logical in arrangement, rich in 1 methodical and practical. The time of its publication material, sound in doctrine, and instructive in its is most opportune The Medical Nrws, March 22, teachings. This book, taken as a whole, is the best : 1884. Legal Medicine. By CHARLES MEYMOTT TIDY, M.B., F.C.S., Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. VOLUME II. Legitimacy and Paternity, Pregnancy, Abortion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial octavo volume of 529 pages. Cloth, $6.00; leather, $7.00. Just Ready. VOLUME I. Containing 664 imperial octavo pages, with two beautiful colored plates. Cloth, $6.00 ; leather, $7.00. Recently Issued. He whose inclinations or necessities lead him to as- due attention to the most recent advances in medical sume the functions of a medical jurist wants a book science. Mr. Tidy's work bids fair to meet this need encyclopaedic in character, in which he may be reason- | satisfactorily. Boston Medical and Surgical Journal, ably sure of finding medico-legal topics discussed with February 8, 1883. judicial fairness, with sufficient completeness, and with ' NervOUS Diseases; Their Description and Treatment. By ALLAN McLANE HAMILTON, M.D., Attending Physician at the Hospital for Epileptics and Paralytics, Blackwell's Island, N. Y., and at the Out-Patients' Department of the New York Hospital. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, 4.00. When the first edition of this good book appeared we best of its kind in any language, which is a handsome gave it our emphatic endorsement, and the present endorsement from an exalted source. The improve- edition enhances our appreciation of the book and its ments in the new edition, and the additions to it, will author as a safe guide to students of clinical neurology, justify its purchase even by those who possess the old. One of the best and most critical of English neurologi- Alienist and Neurologist, April, 1882. cal journals, Brain, has characterized this book as the A System Of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. By WILLIAM LEISHMAN, M.D., Regius Professor of Midwifery in the University of Glasgow, etc. Third American edition, revised by the Author, with additions by JOHN S. PARRY, M.D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50; leather, $5.50; very handsome half Russia, raised bands, $6.00. To the American student the work before us must prove admirably adapted. Complete in all its parts, essentially modern in its teachings, and with demon- strations noted for clearness and precision, it will gain in favor and be recognized as a work of standard merit. The work cannot fail to be popular and is cordially recommended. New Orleans Medical and Surgical Journal, March, 1880. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. By J. NEVINS HYDE, A.M., M.D., Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. In one handsome octavo volume of 570 pages, with 66 beautiful and elaborate illustrations. Cloth, $4.25 ; leather, $5.25. The author has given the student and practitioner a to our literature and a reliable guide to students and work admirably adapted to the wants of each. We ! practitioners in their studies and practice. American can heartily commend the book as a valuable addition Journal of the Medical Sciences, July, 1883. HENRY C LEAS SON & CO., PHILADELPHIA. C. LEA'S SO1ST & CO.'S (LATE HENRY C. LEA) CLASSIFIED CATALOGUE O P MEDICAL AND SURGICAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the following pages, the publishers would state that no pains are spared to secure a continuance of the confi- dence earned for the publications of the house by their careful selection and accuracy and finish of execution. The large number of inquiries received from the profession for a finer class of bindings than is usually placed on medical books has induced us to put certain of our standard publications in half Russia; and, that the growing taste may be encouraged, the prices have been fixed at so small an advance over the cost of sheep as to place it within the means of all to possess a library that shall have attractions as well for the eye as for the mind of the reading practitioner. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail postpaid on receipt of the price, and as the limit of mailable weight has been removed, no difficulty will be experienced in obtaining through the post-office any work in this cata- logue. No risks, however, are assumed either on the money or on the books, and no pub- lications but our own are supplied, so that gentlemen will in most cases find it more con- venient to deal with the nearest bookseller. A handsomely illustrated catalogue will be sent to any address on receipt of a three-ceni stamp. HENKY C. LEA'S SON & CO. Nos. 706 and 708 SANSOM ST., PHILADELPHIA, April, 1884. PROSPECTUS FOR 1GO4. A WEEKLY MEDICAL JOURNAL. SUBSCRIPTION RATES. THE MEDICAL NEWS . . . . . . . FiveDollars. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES . FiveDollars. COMMUTATION RATES. THE MEDICAL NEWS \ Nine Dollars per THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES / annum, in advance. THE MEDICAL NEWS. A National Weekly Medical Periodical, containing- 28 to 32 Quarto Pagres of Reading Matter in Each Issue. In making the change, two years since, from a monthly to a weekly, those in charge of THE MEDICAL NEWS, proposed to furnish the profession what it had never before enjoyed a journal national in the widest sense of the word, devoted to the highest ideals of professional morals and honor, an unsparing enemy of quackery and fraud, a scientific magazine in elaboration, and a newspaper in energy and vitality. They believe that in every respect it has fulfilled its promises. Its readers and contributors are found in every State and Territory ; its Editorial Staff* includes some of the brightest minds in the 2 HENRY C. LEA'S SON & Co.'s PUBLICATIONS The Medical News. profession, and in every issue living topics are editorially discussed in a scholarly and prac- tical manner ; its corps of qualified reporters and correspondents covers all the medical centres of both hemispheres, and secures for its columns the earliest information on matters of medical interest, and its reports of Medical Progress are culled from all the important professional journals published on both continents. In short, its unrivaled organization enables THE NEWS each week to lay upon the table of its readers an epit- ome of a week's advance of the whole medical world. THE NEWS, always endeavoring to enhance its usefulness, has pleasure in announcing to the profession that arrangements have been perfected for the publication during this year of a highly valuable series of practical articles by eminent men on the more im- portant diseases met with by every practitioner in his daily duties. The following gentle- men have kindly promised to aid in carrying out this plan, and the eminence of their names is a guarantee of the value of the papers to be contributed by them. D. HAYES AGNEW, Philadelphia. HARRISON ALLEN, Philadelphia. I. E. ATKINSON, Baltimore. ROBERTS BARTHOLOW, Philadelphia. S. M. BEMISS, New Orleans. L. DUNCAN BULKLEY, New York. CHARLES H. BURNETT, Philadelphia. SAMUEL C. BUSEY, Washington. WILLIAM H. BYFORD, Chicago. P. S. CONNER, Cincinnati. J. M. DA COSTA, Philadelphia. FREDERIC S. DENNIS, New York. FRANK DONALDSON, Baltimore. LOUIS A. DUHRING, Philadelphia. ROBERT T. EDES, Boston. J. FERGUSON, Toronto. AUSTIN FLINT, New York. WILLIAM GOODELL, Philadelphia. SAMUEL D. GROSS, Philadelphia. SAMUEL W. GROSS, Philadelphia. J. F. HEUSTIS, Mobile, Ala. WILLIAM HUNT, Philadelphia. JOSEPH C. HUTCHISON, Brooklyn. JAMES NEVINS HYDE, Chicago. A. REEVES JACKSON, Chicago. EDWARD W. JENKS, Chicago. A. F. A. KING, Washington. OEORGE M. LEFFERTS, New York. WILLIAM T. LUSK, New York. JOHN M. MACKENZIE, Baltimore. HUNTER McGUIRE, Richmond. RICHARD McSHERRY, Baltimore. THOMAS M. MARKOE, New York. S. WEIR MITCHELL, Philadelphia. THOMAS G. MORTON, Philadelphia. L. S. McMURTRY, Danville, Ky. WILLIAM F. NORRIS, Philadelphia. WILLIAM OSLER, Montreal. FESSENDEN N. OTIS, New York. ALONZO B. PALMER, Ann Arbor, Mich. ROSWELL PARK, Buffalo. THEOPHILUS PARVIN, Philadelphia. WILLIAM PEPPER, Philadelphia. F. PEYRE PORCHER, Charleston. THADDEUS A. REAMY, Cincinnati. J. C. REEVE, Dayton, O. LEWIS A. SAYRE, New York. FRANCIS J. SHEPHERD, Montreal. STEPHEN SMITH, New York. J. LEWIS SMITH, New York. LEWIS A. STIMSON, New York. ROBERT W. TAYLOR, New York. WILLIAM THOMSON, Philadelphia. L. McLANE TIFFANY, Baltimore. JAMES TYSON, Philadelphia. ELY VAN DE WARKER, Syracuse, N. Y. J. COLLINS WARREN, Boston. ROBERT F. WEIR, New York. JAMES T. WHITTAKER, Cincinnati. EDWARD WIGGLESWORTH, Boston. E. WILLIAMS, Cincinnati. DAVID W. YANDELL, Louisville. Original articles from foreign authorities may also be expected, the first of which appeared in the issue of January 5th, 1884, on DIGITAL EXPLORATION OF THE BLADDER IN OBSCURE VESICAL DISEASES, WITH ITS RESULTS, by SIR HENRY THOMPSON, of London, Surgeon Extraordinary to the King of the Belgians, etc., with 7 original illustrations. From the high character of the articles already published, a fair conception may be formed of the value of the series to every professional man in active practice. In typographical appearance, THE NEWS of 1884 shows an advance even upon the issues of 1882-83, and nothing has been left undone to economize the time and promote the comfort of its readers. It appears in a double-columned quarto form, printed by the latest improved Hoe speed presses, on handsome paper, from a clear, easily read type, specially cast for its use. THE MEDICAL NEWS employs all the approved methods of modern journalism with the intention of rendering itself indispensable to the profession ; and, in the anticipation of an unprecedented circulation, its subscription has been placed at the exceedingly low rate of $5 per annum, in advance. At this price it ranks as the cheapest medical periodical in this country, and when taken in connection with THE AMERICAN JOURNAL at NINE DOLLARS per annum, it is confidently asserted that a larger amount of material of the highest class is offered than can be obtained elsewhere, even at a much higher price. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Am. Journ. Med. Sci. 3 THE AMERICAN JOURNAL of the MEDICAL SCIENCES, Edited by I. MINIS HAYS, A. M., M. D., Is published Quarterly, on the first days of January, April, July and October, each Number containing over Three Hundred Octavo Pages, fully Illustrated. Founded in 1820, THE AMERICAN JOURNAL, entered with 1884 upon its sixty-fifth consecutive year of faithful and honorable service to the profession. Being the only periodical in the English language capable of presenting elaborate articles the form in which the most important discoveries have always been communicated to the profession THE AMERICAN JOURNAL cannot fail to be of the utmost value to physicians who would keep themselves au courant with the medical thought of the day. It may justly claim that it numbers among its contributors all the most distinguished members of the profession, that its history is identified with the advances of medical knowledge, and that its circu- lation is co-extensive with the use of the English language. During 1884 THE JOURNAL will continue to present those features which have long proved so attractive to its readers. The Original Department will consist of elaborate and richly illustrated articles from the pens of the most eminent members of the profession in all parts of the country. The Review Department will maintain its well-earned reputation for discernment and impartiality, and will contain elaborate reviews of new works and topics of the day, and numerous analytical and bibliographical notices by competent writers. Following these comes the Quarterly Summary of Improvements and Dis- coveries in the Medical Sciences, which, being a classified and arranged condensation of important articles appearing in the chief medical journals of the world, furnishes a compact digest of medical progress abroad and at home. The subscription price of THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES has never been raised during its long career. It is still sent free of postagerfor Five Dollars per annum in advance. Taken together, the JOURNAL and NEWS combine the advantages of the elaborate prep- aration that can be devoted to a quarterly with the prompt conveyance of intelligence by the weekly; while, by special management, duplication of matter is rendered im- possible. It will thus be seen that for the very moderate sum of NINE DOLLARS in advance the subscriber will receive free of postage a weekly and a quarterly journal, both reflecting the latest advances of the medical sciences, and containing an equivalent of more than 4000 octavo pages, stored with the choicest material, original and selected, that can be furnished by the best medical minds of both hemispheres. It would be impossible to find elsewhere so large an amount of matter of the same value offered at so low a price. B^ The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned ; where these are not accessible, remillances for subscrip- tions may be made at the risk of the publishers by forwarding in registered letters. Address, HENRY C. LEA'S SON & Co., Nos. 706 and 708 Sansom St., Philadelphia. * ** Communications to both these periodicals are invited from gentlemen in all parts of the country. Original articles contributed exclusively to either periodical are liberally paid for upon publication. When necessary to elucidate the text, illustrations will be fur- nished without cost to the author. All letters pertaining to the Editorial Department of THE MEDICAL NEWS and THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES should be addressed to the EDITORIAL OFFICES, 1004 Walnut Street, Philadelphia. All letters pertaining to the Business Department of these journals should be addressed exclusively to HENRY C. LEA'S SON & Co., 706 and 708 Sansom Street, Philadelphia. 4 HENRY C. LEA'S Sox & Co.'s PUBLICATIONS Dictionaries. DTTNGLISON, ROBLEY, M.D., Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Containing a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, and the French and other Synonymes, so as to constitute a French as well as an English Medical Lexicon. A new edition, thoroughly revised, and very greatly modified and augmented. By RICHARD J. DUXGLISOX, M. D. In one very large and handsome royal octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; very handsome half Russia, raised bands, $8. The object of the author, from the outset, has not been to make the work a mere lexi- con or dictionary of terms, but to afford under each word a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this enviable reputation. The additions to the vocabulary are more numerous than in any previous revision, and particular attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been greatly improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The volume now contains the matter of at least four ordinary octavos. A book of which every American ought to be j work has been well known for about forty years, proud. When the learned author of the work j and needs no words of praise on our part to recpm- passed away, probably all of us feared lest the book j mend it to the members of the medical, and 1 ike- should not" maintain its place in the advancing wise of the pharmaceutical, profession. The latter science whose terms it defines. Fortunately, Dr. especially are in need of a work which gives ready Richard J. Dunglison, having assisted his father in and reliable information on thousands of subjects the revision of several editions of the work, and and terms which they are liable to encounter in having been, therefore, trained in the methods pursuing their daily vocations, bat with which they and imbued with the spirit of the book, has been cannot be expected to be familiar. The work able to edit it as a work of the kind should be before us fully supplies this want. American Jour- edited to carry it on steadily, without jar or inter- j nal of Pharmacy, Feb. 1874. ruption, along the grooves of thought it has trav- j Particular care has been devoted to deriration lled during its lifetime. To show the magnitude j a nd accentuation of terms. With regard to the of the task which Dr. Dunglison has assumed and i latter, indeed, the present edition may be consid- carried through, it is only necessary to state that I er ed a complete "Pronouncing Dictionary of more than six thousand new subjects have been Medical Science." It is perhaps the most reliable added in the present edition. Philadelphia Medical \ W ork published for the busy practitioner, as it con- Times, Jan. 3, 1874. I tains information upon every medical subject, in About the first book purchased by the medical student is the Medical Dictionary. The lexicon explanatory of technical terms is simply a sine qua non. In a science so extensive and with such col- laterals as medicine, it is as much a necessity also to the practising physician. To meet the wants of a form for ready access, and with a brevity as ad- mirable as it is practical. Southern M&Jical Record. Feb. 1874. A valuable dictionary of the terms employed in medicine and the allied sciences, and of the rela- tions of the subjects treated under each head. It students and most p'hysicians the dictionary must j well deserves the authority and popularity it has be condensed while comprehensive, and practical obtained. British Med. Jour., Oct. 31, 1874. while perspicacious. It was because Dunglison's I Few works of this class exhibit a grander monu- met these indications that it became at once the i ment of patient research and of scientific lore. dictionary of general use wherever medicine was studied in the English language. In no former revision have the. alterations and additions been _ u _ _^ j so great The chief terms have been set in black | cine," "pharmacist" and" dentist^ Western "Lancet, London Lancet, May 13, 1875. Dunglison's Dictionary is incalculably valuable, and indispensable to every practitioner of medi- letter, while the derivatives follow in small caps ; an arrangement which greatly facilitates reference. Cincinnati Lancet and Clinic, Jan. 10, 1874. As a standard work of reference Dunglison's March, 1874. It has the rare merit that it certainly has no rival in the English language for accuracy and extent ot references. London Medical Gazette. HOBLYlf, RICHARD !>., M. D. A Dictionary of the Terms Used in Medicine and the Collateral Sciences. Revised, with numerous additions, by ISAAC HAYS, M. D., late editor of The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 double-columned pages. Cloth, $1.50; leather, $2.00. It is the best book of definitions we have, and ought always to be upon the student's table Southern Medical and Surgical Journal. RODWELL, G. F., F. R. A. S., F. C. S., Lecturer on Natural Science at Clifton College, England. A Dictionary of Science : Comprising Astronomy, Chemistry, Dynamics, Elec- tricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound and Statics. " Contributed by J. T. Bottomley, M. A., F.C. S., William Crookes, F.R.S., F.C.S., Frederick Guthrie, BJL, Ph. D., R. A. Proctor, B.A., F.R.A.S., G. F. Rodwell, Editor, Charles Tomlinson, F.R.S., F.C.S., and Richard Wornell, M.A., B.Sc. Preceded by an Essay on the History of the Physical Sciences. In one handsome octavo volume of 702 pages, with 143 illustrations. Cloth, $5.00. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Compends, Anat. 5 HARTSHORNE, HENRY, A. M., M. &., Lately Professor of Hygiene in the University of Pennsylvania. A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. Second edition, thoroughly revised and greatly improved. In one large royal 12mo. volume of 1028 pages, with 477 illustrations. Cloth, $4.25 ; leather, $5.00. The work is intended as an aid to the medical I its due share of attention. We can conceive such student, and as such appears to fulfil admirably its j a work to be useful, not only to students, but to object by its excellent arrangement, the full com- practitioners as well. It reflects credit upon the Dilation" of facts, the perspicuity and terseness of j industry and energy of its able editor. Boston language, and the clear and instructive illustra- i Medical and Surgical Journal, Sept. 3, 1874. tions. American Journal of Pharmacy, July, 1874. -\Ve can sav, with the strictest truth, that it is the The object of this manual is to afford a conven- best work of the kind with which we areacquainl- ient work of reference to students during the brief ed. It embodies in a condensed form all recent moments at their command while in attendance contributions to practical medicine, and is there- upon medical lectures. It is a favorable sign that fore useful to every busy practitioner throughout it has been found necessary, in a short space of our country, besides being admirably adapted to time, to issue a new and carefully revised edition, the use of students of medicine. The book is The illustrations are very numerous and unusu- ; faithfully and ably executed. Charleston Medical ally clear, and each part seems to have received i Journal. April, 1875. STUDENTS' SERIES^OF MANUALS. A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery. They will be written by eminent Teachers or Examiners, and will be issued in pocket-size 12mo. volumes of 300-540 pages, richly illustrated and at a low price. The following volumes may now be announced : KLEIN'S Elements of Histology, PEPPER'S Surgical Pathology, TREVES' Surgical Applied 'Anatomy, RALFE'S Clinical Chemistry, CLARKE and LOCKWOOD'S Dissectors' Manual, and POWER'S Human Physiology, (Just ready) ; ROBERTSON'S Physical Physiology, BRUCE'S Materia Medica and Therapeutics, BELLAMY'S Operative Surgery, and BELL'S Comparative Physiology and Anatomy, (In active preparation for early publication.) For separate notices see index on last page. NEILL, JOHN, M. T>., and SMITH, F. G., M. D., Late Surgeon to the Pcnna. Hospital. Prof, of the Institutes of Mcd. in the Univ. of Penna. An Analytical Compendium of the Various Branches of Medical Science, for the use and examination of Students. A new edition, revised and improved. In one very large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4; strongly bound in leather, raised bands, $4.75. LUDLOW, J.L.,M.I>., Consulting Physician to the Philadelphia Hospital, etc. A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised, and greatly 'extended and enlarged. In one handsome royal 12mo. volume of 816 large pages, with 370 illus- trations. Cloth, $3.25 ; leather, $3.75. The arrangement of this volume in the form of question and answer renders it espe- cially suitable for the office examination of students, and for those preparing for graduation. WILSON, ERASMUS, F. R. S. A System of Human Anatomy, General and Special. Edited by W. H. GOBRECHT, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00; leather, $5.00. SMITH, H. H., M. D., and HORNER, WM. E.,M.D. 9 Emeritus Prof, of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna. An Anatomical Atlas, Illustrative of the Structure of the Human Body. In one large imperial octavo volume of 200 pages, with 634 beautiful figures. Cloth, $4.50. CLELAND, JOHN, M. D., F. R. S., Professor of Anatomy and Physiology in Queen's College, Galway. A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Cloth, $1.25. BELLAMY, EDWARD, F. R. C. S., Senior Assistant-Surgeon to the Charing-Cross Hospital, London. The Student's Guide to Surgical Anatomy : Being a Description of the most Important Surgical Regions of the Human Body, and intended as an Introduction to Operative Surgery. In one 12mo. volume of 300 page's, with 50 illustrations. Cloth, $2.25. EARTSHORNE'S HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second edition, revised. In one royal 12mo. volume of 310 pages, with 220 HORXER'S SPECIAL ANATOMY AND HISTOL- OGY. Eighth edition, extensively revised and modified. In two octavo volumes of 1007 pages, woodcuts. Cloth, $1.75. with 320 woodcuts. Cloth, $0.00. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Anatomy. ALLEN, HARRISON, M. D., Professor of Physiology in the University of Pennsylvania. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. "With an Intro- ductory Chapter on Histology. By E. O. SHAKESPEARE, M. D., Ophthalmologist to the Philadelphia Hospital. In one large and handsome quarto volume of about 700 double- columned pages, with 380 illustrations on 109 lithographic plates, many of which are in colors, and about 150 engravings in the text. In six Sections, each in a portfolio. Section I. HISTOLOGY (Just ready). Section II. BONES AND JOINTS (Just ready). Section III. MUSCLES AND FASCIA (Just ready). Section IV. ARTERIES, VEINS AND LYMPHATICS (Just ready). Section V. NERVOUS SYSTEM (Just ready). Section VI. ORGANS OF SENSE, OF DIGESTION AND GENITO-URINARY ORGANS (In press). Price per Section, $3.50. For sale by subscription only. Apply to the Publishers Extract from Introduction. It is the design of this book to present the facts of human anatomy in the manner best suited to the requirements of the student and the practitioner of medicine. The author believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in addition to the text descriptive of the subject, a systematic presentation of such anatomical facts as can be applied to practice. A book which will be at once accurate in statement and concise in terms ; which will be an acceptable expression of the present state of the science of anatomy ; which will exclude nothing that can be made applicable to the medical art, and which will thus embrace all of surgical importance, while omitting nothing of value to clinical medicine, would appear to have an excuse for existence in a country where most surgeons are general practitioners, and where there are few general practitioners who have no interest in surgery. Among other matters, the book will be found to contain an elaborate description of the tissues; an account of the normal development of the body; a section on the nature and varieties of monstrosities ; a section on the method of conducting post-mortem examina- tions ; and a section on the study of the superficies of the body taken as a guide to the position of the deeper structures. These will appear in their appropriate places, duly subordinated to the design of presenting a text essentially anatomical. A book like this is an ideal rarely realized. It brought to it a mind well prepared for the task by is a mine of wealth in the in form at ion it gives. It extensive reading, critical judgment and literary ditlers from all preceding anatomies in its scope, i ability. We can cordially recommend the work and is, we believe, a vast improvement upon them to the profession, believing that it is suited not all. The chief novelty about the book, and really one of the greatest needs in anatomy, is the ex- tension of the text to cover not only anatomical descriptions, but the uses of anatomy in studying disease. This is done by stating the narrower topographical relations, and also the wider clin- ical relations, of the more remote parts, by giving a brief account of the uses of the various organs, and by qfloting cases which illustrate the "local- ization of diseased action." The plates are beau- tiful specimens of work by one who long since won a deserved reputation as an artist. The Medi- cal News, October 21, 1882. The appearance of the book marks an epoch in medical literature. It is the first important work only to those of scientific tastes, but that it will be of use to the practising physician. Boston Medical and Surgical Journal, Jan. 11, 1883. It is to be considered a study of applied anatomy in its widest sense a systematic presentation of such anatomical facts as can be applied to the practice of medicine as well as of surgery. Our author is concise, accurate and practicaj in his statements, and succeeds admirably in infusing an interest into the study of what is generally con- sidered a dry subject. The department of Histol- ogy is treated in a masterly manner, and the ground is travelled over by one thoroughly famil- iar with it. The illustrations are made with great care, and are simply superb. It would be impos- on human anatomy that has appeared in America; | sible, except in a general way, to point out the and, more than this, its scope is new and original, excellence of the work of the author in the second it is in tended to be both descriptive and topograph- Section that devoted to the consideration of the ical, scientific and practical, so that while satisfy- | Bones and Joints. There is as much of practical ing the anatomist it will be of value to the practfs- | application of anatomical points to the every-day ing physician. The names of the parts, muscular | wants of the medical clinician as to those of the attachments, etc., are printed either on the figure operating surgeon. In fact, few general practi- or close beside, so that they are easily recognized, tioners will read the work without a feeling of sur- The illustrations made from the author's dissec- ' prised gratification that so many points, concern- tions deserve the highest praise. They are well con- ing which they may never have thought before, ceived and well executed, handsome artistically ! are so well presented for their consideration. It and clear anatomically. As the author points out, is a work which is destined to be the best of its such a work as he has undertaken is necessarily encyclopaedic, and the result shows that he has kind in any language. Medical Record, IS'ov. 25, '82. CLARKE,W. B., F.R.C.S. & LOCKWOOD,C. B., F.R.C.S. Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, $1.50. Just ready. See Students' Series of Manuals, page 5. This is a very excellent manual for the use of the student who desires to learn anatomy. The meth- ods of demonstration seem to us very satisfactory. There are many woodcuts which, for the most part, are good and instructive. The book is neat and convenient. We are glad to recommend it. Boston Medical and Surgical Journal, Jan. 17, 1884. TREVES, FREDERICK, F. R. C. 8., Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital, Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illus- trations. Limp cloth, red edges, $2.00. Just ready. See Students' Series of Manuals, page 5. He has produced a work which will command a larger circle of readers than the class for which it was written. This union of a thorough, practical acquaintance with these fundamental branches, quickened by daily use as a teacher and practi tioner, has enabled our author to prepare a work which it would be a most difficult task to excel. The American Practitioner, Feb., 1884. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Anatomy. 7 GRAY, HENRY, F. R. S., Lecturer on Anatomy at St. George's Hospital, London. Anatomy, Descriptive and Surgical. The Drawings by H. V. CARTER, M. D., and Dr. WESTMACOTT. The dissections jointly by the AUTHOR and Dr. CARTER. With an Introduction on General Anatomy and Development by T. HOLMES, M. A., Surgeon to St. George's Hospital. Edited by T. Pickering Pick, F. E. C. S., Surgeon and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of Surgeons of England. A new American from the tenth enlarged and improved London edition. To which is added the second American from the latest English edition of LANDMARKS, MEDICAL AND SURGICAL, by LUTHER HOLDEN, F. K. C. S., author of " Human Osteology," " A Manual of Dissections," etc. In one imperial octavo volume of 1023 pages, with 564 large and elaborate engravings on wood. Cloth, $6.00 ; leather, $7.00 ; very handsome half Russia, raised bands, $7.50. Just ready. This work covers a more extended range of subjects than is customary in the ordinary text-books, giving not only the details necessary for the student, but also the application of those details to the practice of medicine and surgery. It thus forms both a guide for the learner and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting-room. Combining, as it does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of great service to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, has been appended to the present edition as it was to the previous one. This work gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. This well-known work comes to us as the latest There is probably no work used so universally by physicians and medical students as this one. American from the tenth English edition. As its title indicates, it has passed through many hands and has received many additions and revisions. The work is not susceptible of more improvement. Taking it all in all, its size, manner of make-up, its character and illustrations, its general accur- acy of description, its practical aim, and its per- spicuity of style, it is the Anatomy best adapted to the wants of the student and practitioner. Medical Record, Sept. 15, 1883. | 1, 1883. by phy: It is deserving of the confidence that they repose in it. If the present edition is compared with that issued two years ago, one will readily see how much it has been improved in that time. Many pages have been added to the text, especially in those parts that treat of histology, and many new cuts have been introduced and old ones modified. Journal of the American Medical Association, Sept. ALSO FOR SALE SEPARATE HOLDEN, LUTHER, F. R. C. S., Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by W. W. KEEN, M. D., Professor of Artistic Anatomy in the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. almost to learn it by heart. It teaches diagnosis by This little book is all that can be desired within its scope, and its contents will be found simply in- valuable to the young surgeon or physician, since they bring before him such data as he requires at every examination of a patient. It is written in language so clear and concise that one ought external examination, ocular and palpable, of the bodv, with such as directly bear the student's and young practitioner's book. Phy- sician and Surgeon, Nov. 1881. anatomical and physiological facts on the subject. It is eminently DALTON, JOHN C., M. D., Professor of Physiology in the College of Physicians and Surgeons, New York. The Topographical Anatomy of the Brain. In one very handsome quarto volume of about 200 pages of descriptive text. Illustrated with forty-nine life-size photo- graphic illustrations of Brain Sections, with a like number of outline explanatory plates, as well as many carefully-executed woodcuts through the text. In press. ELLIS, GEORGE VINER, Emeritus Professor of Anatomy in University College, London. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. From the eighth and revised London edition. In one very handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. special line. The descriptions are clear, and the methods of pursuing anatomical investigations are given with such detail that the book is honestly Ellis' Demonstrations is the favorite text-book of the English student of anatomy. In passing through eight editions it has been so revised and adapted to the needs of the student that it would .. seem that it had almost reached perfection in this June, 1879. entitled to its name. St. Louis Clinical Record, 8 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Physiology. D ALTON, JOHN C., M. J)., Professor of Physiology in the College of Physicians and Surgeons, New York, etc. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. The merits of Professor Dalton's text-book, his smooth and pleasing style, the remarkable clear- ness of his descriptions, which leave not a chapter obscure, his cautious judgment and the general correctness of his facts, are perfectly known. They have made his text-book the one most familiar to American students. Med. Record, March 4, 1882. Certainly no physiological work has ever issued from the press that presented its subject-matter in a clearer and more attractive light. Almost every previous one, and will tend to keep the profession posted as to the most recent additions to our physiological knowledge. Michigan Medical News, April, 1882. One can scarcely open a college catalogue that does not have mention of Dalton's Physiology as the recommended text or consultation-book. For American students we would unreservedly recom- mend the edition of Dr. Dalton's work now before _ _ us. Let it suffice to state that revisions have been page bears evidence of the exhaustive revision I made to such an extent as to bring the volume as hat has taken place. The material is placed in a fully up to the present state of physiological knowl- more compact form, yet its delightful charm is re- edge as it is practicable for any author of a book tained, and no subject is thrown into obscurity, to do. Virginia Medical Monthly, July, 1882. Altogether this edition is far in advance of any FOSTER, MICHAEL, M. D., F. R. S., Professor of Physiology in Cambridge University, England. Text-Book of Physiology. Second American from the third English edition. Edited, with extensive notes and additions, by EDWARD T. REICHERT, M. D., late Demonstrator of Experimental Therapeutics in the University of Pennsylvania, In one handsome royal 12mo. volume of 999 pages, with 259 illust. Cloth, $3.25; leather, $3.75. A more compact and scientific work on physiol- ogy has never been published, and we believe our- selves not to be mistaken in asserting that it has now been introduced into every medical college in which the English language is spoken. This work conforms to the latest researches into zoology and comparative anatomy, and takes into consid- eration the late discoveries in physiological chem- istry and the experiments in localization of Ferrier and others. The arrangement followed is such as to render the whole subject lucid and well con- nected in its various parts. Chicago Medical Jour- nal and Examiner, August, 1882. Dr. Michael Foster's Manual of Pht/siologi/ has been translated into the German, with a preface, by Professor Kiihne. KUhne points out in his preface that the abundant material, in spite of the moderate size, is not condensed to systematic shortness, but the whole is related in a narrative style. The translation of it into German is a well- merited compliment, since Germany is the es- pecial home of physiology, and its literature is abundantly rich in" text-books, monographs and periodicals on physiology. American Medical i- Weekly, June 18, 1881. POWER, HENRY, M. B., F. R. C. S., Examiner in Physiology, Royal College of Surgeons of England. Human Physiology. In one handsome pocket-size 12mo. volume of 396 pages, with 47 illustrations. Cloth, $1.50. Just ready. See Students' Series of Manuals, page 5. This little work is deserving of the highest praise, and we can hardly conceive how the main facts of this science could have been more clearly or concisely stated. The price of the work is such as to place it within the reach of all, while the ex- cellence of its text will certainly secure for it most favorable commendation. Cincinnati Lancet and Clinic, Feb. 1C, 1884. ROBERTSON, J. McGREGOR, M. A., M. B., Muirhead Demonstrator of Physiology, University of Glasgow. Physical Physiology. In active preparation. See Students' Series of Manuals, page 5. BELL, F. JEFFREY, M. A., Professor of Comparative Anatomy at King's College, London. Comparative Physiology and Anatomy. In active preparation for early publication. See Students' Series of Manuals, page 5. CARPENTER, WM. B., M. D., F. R. S., F. G. S., F. L. S., Registrar to the University of London, etc. Principles of Human Physiology. Edited by HENRY POWER, M.B., Lond., F. R. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the eighth revised and enlarged edition, with notes and additions by FRANCIS G. SMITH, M. D., late Professor of the Institutes of Medicine in the University of Pennsylvania. In one very large and handsome octavo volume of 1083 pages, with two plates and 373 illus- trations Cloth, $5.50 ; leather, $6.50 ; half Russia, $7. The editors have, with their additions to the tion. We have been agreeably surprised to find the volume so complete in regard to the structure and functions of the nervous system in all its rela- tions a suhjec't that in many respects is one of the most difficult of all, in the whole range of physiology, upon which to produce a full and satis- factory treatise of the class to which the one be- only work on physiology in our language that, in the fullest sense of the word, is the production of a philosopher as well as a physiologist, brought it up fully to the standard of our knowledge of its subject at the present day. The additions by the American editor give to the work as it is a consid- erable value beyond that of the last English edi- CARPENTER'S PRIZE ESSAY ON THE USE AND ABUSE OF ALCOHOLIC LIQUORS IN HEALTH AND DIS- EASE. With a preface by D. F. CONDIE, M. D., and explanations of scientific words. In one small 12mo. volume of 178 pages. Cloth, GO cents. fore us belongs. Jl.of Nerv. andJUent. i>is.,Apr.,'77. LEHMANN'S MANUAL OF CHEMICAL PHYS- IOLOGY. Translated from the Geimar with notes and additions, by J. CHESTON MORRIS, M. D. In one octavo volume of 327 pages, with 41 illus- trations. Cloth, $2.25. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Chemistry. ATTFIELD, JOHN, Ph. D., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. Chemistry, General, Medical and Pharmaceutical; Including the Chem- istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. A new American, from the tenth English edition, specially revised by the Author. In one handsome royal 12mo. volume of 728 pages, with 87 illustrations. Cloth, $2.50 ; leather, 3.00. Just ready. It is a book on which too much praise cannot be bestowed. As a text book for medical schools it is unsurpassable in the present state of clinical science, and having been prepared with a special view towards medicine and pharmacy, it is alike indispensable to all persons engaged in those de- partments of science. It includes the whole chemistry of thelast Pharmacopoeia. Pacific Medi- cal and Surgical Journal, Jan. 1884. The clearness, system and thoroughness of this manual have made it for the last sixteen years the constant companion of the medical and pharma- ceutical student. Within this time it has under- gone ten editions, which have progressively en- larged its scope and general usefulness. We again welcome the book, and give it a cordial endorse- ment. New Orleans Medical and Surgical Journal , January, 1884. BLOXAM, CHARLES L., Professor of Chemistry in King's College, London. Chemistry, Inorganic and Organic. New American from the fifth Lon- don edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Cloth, 3.75 ; leather, $4.75. Just ready. The general plan of this work remains the same as in previous editions, the evident object being to give clear and concise descriptions of all known elements and of their most important compounds, with explanations of the chemical laws and principles involved. We gladly repeat now the opinion we expressed about a former edition, that we regard Bloxam's Chemistry as one of the best treatises on general and applied chemistry. American Jour, of Pharmacy, Dec. 1883. Commentfrom us on this standard work is almost superfluous. It differs widely in scope and aim from that of Attfleld, and in its way is equally beyond criticism. It adopts the most direct meth- ods in stating the principles, hypotheses and facts of the science. Its language is so terse and lucid, and its arrangement of matter so logical in se- quence, that the student never has occasion to complain that chemistry is a hard study. Much attention is paid in this work to experimental illustrations of chemical principles and phenom- ena, and the mode of conducting these experi- ments. The book maintains the position it has always held as one of the best manuals of general chemistry in the English language. The Detroit Lancet, February, 1884. This ample and thorough treatise on chemistry has in this revision been extended and brought down to the latest date, so as to include a notice of all important recent discoveries in this progressive science. In this edition the theoretical portions have received especial attention, so as to bring them into accordance with modern views. Sled, and Surgical Reporter, Dec. 1, 1883. REMSEN, IRA, M. D., Ph. !>., Professor of Chemistry in the Johns Hopkins University, Baltimore. Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. Second and revised edition. In one handsome royal 12mo. volume of 240 pages. Cloth, $1.75. Just ready. io the average text books of the day. American Journal of Science, March, 1884. The book is a valuable contribution to the chemi- cal literature of instruction. That ill so few years a second edition has been called for indicates that many chemical teachers have been found ready to endorse its plan and to adopt its methods. In this edition a considerable proportion of the hook has been rewritten, much new matter has been added and the whole has been brought up to date. We earnestly commend this book to every student of chemistry. The high reputation of the author assures its accuracy in all matters of fact, and its judicious conservatism in matters of theory, com- bined with the. fulness with which, in a small compass, the present attitude of chemical science towards the constitution of compounds is con- sidered, gives it a value much beyond that accorded We would heartily recommend it to any student who desires to acquaint himself with the subject. In the matter we can find nothing to criticise. Every point is explained with perfect satisfaction, so that the merest tyro may understand. Physician and Surgeon, Dec. 1883. When the first edition made its appearance, w welcomed it as a very valuable addition to litera- ture; the more we have consulted it since that time the more we have appreciated its value. The book deserves to be placed in the hands of every student of chemistry. American Journal of Phar- macy, December, 1883. FOWNES, GEORGE, Ph. D. A Manual of Elementary Chemistry ; Theoretical and Practical. Kevised and corrected by HENRY WATTS, B. A., F. R. S., Editor of A DICTIONARY OF CHEMISTRY, etc. A new American from the twelfth and enlarged London edition. Edited by ROBERT BRIDGES, M. D. In one large royal 12mo. volume of 1031 pages, with 177 illustrations on wood and a colored plate. Cloth, $2.75 ; leather, $3.25. The book opens with a treatise on Chemical Physics, including Heat, Light, Magnetism and Electricity. These subjects are treated clearly and briefly, but enough is given to enable ttie stu- of late years, the chapter on the General Principles of Chemical Philosophy has been entirely rewrit- ten. The latest views on Equivalents, Quantiva- lence, etc., are clearly and fully set forth. This jgti dent to comprehend the facts and laws of Chemis- try proper. It is the fashion of late years to omit | cess these topics from works on chemistry, but their has reached its twelfth edition. Ohio Medical Be- t edition is a great improvement upon its prede- sors, which is saying not a little of a book that omission is not to be commended. As was required by the great advance in the science of Chemistry corder, Oct., 1878. Wohler's Outlines of Organic Chemistry. Edited by FITTIO. Translated by IRA REMSEN, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 10 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Chemistry. HOFFMANN, F., A. M., Ph.D., & POWER F.B., Public Analyst to the State of New York. Prof, of Anal. Chtm. Phil. Coll. of Pharmacy. A Manual of Chemical Analysis, as applied to the Examination of Medicinal Chemicals and their Preparations. Being a Guide for the Determin..Jionof their Identity and Quality, and for the Detection of Impurities and Adulterat.' ins. For the use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and Medical Students. Third edition, entirely rewritten and much enlarged. In one very handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. We congratulate the author on the appearance full without being redundant, so that the tyro can of the third edition of this work, published for the easily understand them and practise the processes first time in this country also. It is admirable and j successfully. The work is thus well adapted as a the information it undertakes to supply is both j book of reference for practical use, and calculated extensive and trustworthy. The selection of pro- j to impart such information as in each particular cesses for determining the purity of the sub^tan ces of which it treats is excellent and tne descrip- tion of them singularly explicit. Moreover, it is exceptionally free from typographical errors. We have no hesitation in recommending it to those who are engaged either in the manufacture or the testing of medicinal chemicals. London Pharma- ceutical Journal and Transactions, 1883. Viewed in regard to its general aims as well as to the manner in which they have been carried out, the work will be found as complete as can well be desired. The descriptions of operations are case may be useful or required witiiin the limit of its objects. American Journal of P/iar., May, 1883. This work has undergone a very considerable change since the first edition appeared in 1873; in its present form it is a marked improvement on the earlier editions. The authors are to be congratulated on the manner in which they have remodelled the work ; in its present form it is sure to prove a valuable aid in the practice of pharmaceutical chemistry. Lend. Chemist, and Druggist, June 15, 1883. In one 12mo. volume WATTS, HENRY, R. A., F. R. S. Author of "A Dictionary of Chemistry," etc. A Manual of Physical and Inorganic Chemistry. of 500 pages with 150 illustrations. In press. CLOWES, FRANK, D. Sc., London, Senior Science- Master at the High School, Newcastle-under-Lyme, etc. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. Second American from the third and revised English edition. In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, $2.50. The chief object of the author of the present work was to furnish one which was sufficiently elemen- tary in the description of apparatuses, chemicals, modes of experimentation, etc., so as to "reduce to a minimum the amount of assistance required from a teacher." It is a generally recognized fact that one of the most serious hindrances to the utility of many of the smaller text-books is the too great conciseness of the language employed, which renders it unintelligible to the primary student unless supplemented by copious verbal explana- tions from the teacher. The Elementary treatise of Dr. Clowes, examined with reference to the above claims, is found to be a great improvement on other elementary works. A student who care- fully reads this text will scarcely need the assist- ance of a tutor in following out any of the ex- periments described. Va.Med. Monthly, Ap., 1881. RALFE, CHARLES H., M. D., F. R. C. P., Assistant Physician at the London Hospital. Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 5. This is one of the most instructive little works that we have met with in a long time. The author is a physician and physiologist, as well as a chem- ist, consequently the book is unqualifiedly pi tical, telling the physician just what he ougn know, of the applications of chemistry in medi- cine. Dr. Ralfe is thoroughly acquainted with the latest contributions to his science, and it is quite refreshing to find the subject dealt with so clearly and simply, yet in such evident harmony with the modern scientific methods and spirit. Medical Record, February 2, 1884. CLASSEN, ALEXANDER, Professor in the Royal Polytechnic School, Aix-la-Chapelle. Elementary Quantitative Analysis. Translated, with notes and additions, by EDGAR F. SMITH, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, University of Pennsylvania. In one handsome royal 12mo. volume of 324 pages, with 36 illustrations. Cloth, $2.00. It is probably the best manual of an elementary I and then advancing to the analysis of minerals and nature extant, insomuch as its methods are the | such products as are met with in applied chemis- best. It teaches by examples, commencing with try. It is an indispensable book for students in single determinations, followed by separations, chemistry. Boston Journal of Chemistry, Ocl 1878. GREENE, WILLIAM H., M. &*, Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. A Manual of Medical Chemistry. For the use of Students. Based upon Bow- man's Medical Chemistry. In one 12mo. volume' of 310 pages, with 74 illus. Cloth, $1.75. It is a concise manual of three hundred pages, [ the recognition of compounds due to pathological giving an excellent summary of the best methods of analyzing the liquids and solids of the body, both for the estimation of their normal constituents and conditions. The detection of poisons is treated with sufficient fulness for the purpose of the stu- dent or practitioner. Boston Jl. of Chem., June, '80. A MANUAL OF QUALITATIVE ANALYSIS. By Robert Galloway, F. C. S. From the sixth London edition. In one royal 12mo. volume, with illustrations. Preparing. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Pharm., Mat. Med. 11 PARRISH, EDWARD, Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. A Treatise on Pharmacy : designed as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fifth edition, thoroughly revised, by THOMAS S. WIEGAND, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. JMS< ready. From the Preface to the Fifth Edition. A new edition of Mr. Parrish's standard work has been rendered an imperative necessity, not only by the late revision of the U. S. Pharmacopoeia, but also by the great advance in chemical and pharmaceutical science within the last decade. The changes thus required have rendered the task of the editor by no means light, and have considerably increased the size of the volume, in spite of earnest efforts at condensation and the omission of all obsolete matter. The new preparations of the Pharmacopoeia have been introduced, to- gether with its tests for chemical and officinal compounds, and its system of parts by weight in place of definite quantities. The entire chemical section has been rearranged in con- formity with the present views of that science, and the subject of testing, both qualitative and quantitative, has been rendered as complete as the scope of the work would permit and the wants of students are likely to require. All general pharmaceutical and chemical pro- cesses have been arranged in a separate part, thus facilitating reference and avoiding repetition, while special apparatus for particular classes of preparations has been placed under those classes. The syllabi, which proved so valuable a feature of previous editions, and on which Professor Maisch bestowed so much care, have been retained; many of them have been rewritten and new ones introduced. All new remedies of interest have been added, and in the chapter on elixirs some new formulae of much popularity have been given. The editor need only add that he has spared no labor or care in the hope of ren- dering the work as acceptable as it has hitherto been to the student and the pharmaceutist. This well-known work presents itself now based upon the recently revised new Pharmacopeia. Several important modifications of the internal arrangement have been made, and we believe they will be found to increase the practical use- fulness of the book. Each page bears evidence of the care bestowed upon it, and conveys valuable information from the rich store of the editor's experience. In fact, all that relates to practical pharmacy apparatus, processes and dispensing has been arranged and described with clearness in its various aspects, so as to afford aid and advice alike to the student and to the practical pharma- cist. The work is judiciously illustrated with good woodcuts American Journal of Pharmacy, Janu- ary, 1884. HERMANN, Dr. L., Professor of Physiology in the University of Zurich. Experimental Pharmacology. A Handbook of Methods for Determining the Physiological Actions of Drugs. Translated, with the Author's permission, and with extensive additions, by ROBERT MEADE SMITH, M. D., Demonstrator of Physiology in the University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 illustrations. Cloth, $1.50. Just ready. The selection of animals and their management, the paths of elimination and changes of poisons in the body, the explanation of the symptoms pro- duced by poisons, alterations in tissue, in the re- productive function and in temperature, action on muscles and in nerves, anatomical and chemical changes produced by poisons, all are successively passed in review in a practical instructive fashion, which speaks well for both the author and the translator. The book is deserving of an enco- mium as a correct exponent of the spirit and tendencies of modern pharmacological research. After closely perusing the pages, all laden to over- flowing with the richest facts of physiological in- vestigation, and after following the astounding progress of toxic pharmacology as revealed by the author, we feel that we are fast approaching the realization of that Utopian dream in whicli we behold experimental and clinical experience firmly and inseparably united. It is a reliable, concise and practical vade mecum for the time- pressed worker in the laboratory. New Orleans Medical and Surgical Journal, May, 1883. MAISCH, JOHNM., Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists and Physicians. New edition. In one handsome royal 12mo. volume. Preparing. A few notices of the previous edition are appended. clear and simple in its style, concise, since it would be difficult to find in it a superfluous word, and yet sufficiently explicit to satisfy the most critical. Chicago Med. Jnl. and Exam., Aug. 1882. _ A book evidently written for a purpose, and not simply for the purpose of writing a book. It is comprehensive, as it refers to all, or nearly all, that is of essential value in organic materia medica, D UJARDIN-BEA UMETZ, Member of the Academy of Medicine, Physician to the Hdpital St. Antoine, Paris. Dictionary of Therapeutics, Materia Medica, Pharmacology, Tox- icology and Mineral Waters. Translated with notes and additions. Preparing. GRIFFITH, ROBERT EGLESFIELD, M. D. A Universal Formulary, containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- ists. Third edition, thoroughly revised, with numerous additions, by JOHN M. MAISCH, Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leath er, $5.50. 12 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Mat. Med., Therap. STILLE, A., M. D., LL. &., & MAISCH, J. M.,Phar.I>., Professor of the Theory and Practice of Prof of Mat. Med. and Botanif in Phila. Medicine and of Clinical Medicine in the College of Pharmaci/,Sec'i/to the Aineri- University of Pennsylvania. can Pharmaceutical Association. The National Dispensatory : Containing the Natural History, Chemistry, Phar- macy, Actions and Uses of Medicines, including those recognized in the Pharmacopeias of the United States, Great Britain and Germany, with numerous references to the French Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent imperial octavo volume of about 1800 pages, with several hundred line engravings. In press. The publishers have much pleasure in announcing to the Medical and Pharmaceutical Professions that a new edition of this important work is in press, and that it will appear in the shortest time consistent with the care requisite for printing a work of immense detail, where absolute accuracy is of such supreme importance. Besides its revision on the basis of the U. S. Pharmacopoeia of 1880, it will include all the advances made in its department during the period elapsed since the preparation of that work. To this end all recent medical and pharmaceutical literature, both domestic and foreign, has been thor- oughly sifted, and everything that is new and important has been introduced, together with the results of original investigations. To accord with the new Pharmacopoeia the officinal formulae are given in parts by weight, but in every instance, for the sake of con- venience, the same proportions are also expressed in ordinary weights and measures. The Therapeutical Index has been enlarged so that it contains about 8000 references, arranged under an alphabetical list of diseases, thus placing at the disposal of the practitioner, in the most convenient manner, the vast stores of therapeutical knowledge constantly needed in his daily practice. The work may therefore be justly regarded as a complete Encyclo- paedia of Materia Medica and Therapeutics, including 1883. The exhaustion of two very large editions of THE NATIONAL DISPENSATORY since 1879 is the most conclusive testimony as to the necessity which demanded its preparation and to the admirable manner in which that duty has been performed. In this revision the authors have sought to add to its usefulness by including everything properly coming within its scope which can be of use to the physician or pharmacist and at the same time by the utmost conciseness and by the omission of all obsolete matter to prevent undue increase in the size of the volume. No care will be spared by the publishers to render its typographical execution worthy of its wide reputation and universal use as the tandard authority. FARQUHARSON, ROBERT, M. D., Lecturer on Materia Medica at St. Mary's Hospital Medical School. A Guide to Therapeutics and Materia Mediea. Third American edition, specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by FRANK WOODBURY, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25. Dr. Farquharson's Therapeutics is constructed upon a plan which brines before the reader all the essential points with reference to the properties of drugs. It impresses these upon him in such a way as to enable him to take a clear view of the actions of medicines and the disordered conditions in which they must prove useful. The double-col- umned pages one side containing the recognized physiological action of the medicine, and the other the disease in which observers (who are nearly al- ways mentioned) have obtained from it good re- sults make a very good arrangement. The early chapter containing rules for prescribing is excel- lent. We have much pleasure in once more draw- ing attention to this valuable and well-digested book, and predict for it a continued successful ca- reer. Canada Med. and Surg. Journal, Dec. 1882. BRUNTON, T. LATTDER, M. D., Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, etc. A Manual of Materia Medica and Therapeutics, including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. In one handsome octavo volume. In press. BRUCE, J. MITCHELL, M. D., F. R. C. P. Materia Medica and Therapeutics. In active preparation for early publication. See Students' Series of Manuals, page 5. STILLE, ALFRED, M. J>., LL. D., Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Pcnna. Therapeutics and Materia Medica. A Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and Plistory. Fourth edition, revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. Cloth, $10.00; leather, $12.00; very handsome half Eussia, raised bands, $13.00. The rapid exhaustion of three editions and the universal favor with which the work has been re- ceived by the medical profession are sufficient proof of its excellence as a repertory of practical and useful information for the physician. The edition before us fully sustains this verdict. American Journal of Pharmacy, Feb. 1875. We can hardly admit that it has a rival in the multitude of its citations and the fulness of its research into clinical histories, and wemustassign it a place in the physician's library; not, indeed, as fully representing the present state of knowledge in pharmacodynamies, but as by far the most com- plete treatise upon the clinical and practical side of the question. Boston Medical and Surgical Jour- nal, Nov. 6, 1874. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Therap., Pathol., Histol. 13 COATS, JOSEPH, M. D., F. F. P. S., Pathologist to the Glasgow Western Infirmary. A Treatise on Pathology. In one very handsome octavo volume of [829 pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. Just ready. The work before us treats the subject of Path- j condition effected in structures by disease, r nnd ology more extensively than it is usually treated | points out the characteristics of various moiliid in similar works. Medical students as well as j agencies, .o that they can be easily recognized. 1'ut, physicians, who desire a work for study or refer- ence, that treats the subjects in the various de- partments in a very thorough manner, but without prolixity, will certainly give this one the prefer- ence to any with which we are acquainted. It sets forth the most recent discoveries, exhibits, in an interesting manner, the changes from a normal not limited to morbid anatomy,it explains fully how the functions of organs are disturbed by abnormal conditions. There is nothing belonging to its de. partment of medicine that is not as fully elucidated as our present knowledge will admit. Cincinnati Medical A'eirs, Oct. 1883. WOODHEAD, a. SIMS, M. D., F. It. C. P. E., Demonstrator of Pathology in the University of Edinburgh. Practical Pathology. A Manual for Students and Practitioners. Jn one very beautiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. Just ready. It cannot often be said in these days of literary activity, that a book meets a distinct want, that it opens up new ground, and that it is sure to be largely in request. All these things are perfectly true of tjie admirable and handsome volume before us. It is literally the first thorough attempt to deal fully with the subject of practical pathology, es- pecially in its histological aspect, and in manner and scope it stands alone. The vast majority of the figures interpolated in the text are colored, and colored so as to reproduce with tolerable exactitude the appearances of sections stained with various reagents. We have formed a very high opinion of this work, and we candidly admit that there is in it little to which exception could possibly be taken. It is manifestly the product of one who has him- self travelled over the whole field and who is ski lied not merely in the art of histology, but in the obser- vation and interpretation of morbid changes. The work is sure to command a wide circulation. It should do much to encourage the pursuit of path- ology, since such advantages in histological s'tudy have never before been offered. The Lancet, Jan. 5, 1884. CORNIL, F., and RANVIER, L., Prof, in the Faculty of Med. of Paris. Prof, in the College of France. A Manual of Pathological Histology. Translated, with notes and additions, by E. O. SHAKESPEARE, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia Hospital, and by J. HENRY C. SIMES, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with 360 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Russia, raised bands, $7. We have no hesitation in cordially recommend- ing the translation of Cornil and Ranvier's " Patho- logical Histology" as the best work of the kind in any language, and as giving to its readers a trust- worthy guide in obtaining a broad and solid basis for the appreciation of the practical bearings of pathological anatomy. American Journal of the Medical Sciences, April, 1880. One of the most complete volumes on patholog- ical histology we have ever seen. The plan of study embraced within its pages is essentially practical. Normal tissues are discussed, and after their thor- ough demonstration we are able to compare any pathological change which has occurred in them. Thus side by side physiological and pathological anatomy go hand in "hand, affording that best of all processes in demonstrations, comparison. The admirable arrangement of the work affords facility in the study of any part of the human economy. New Orleans Medical and Surgical Journal, June,1882. KLEIN, E., M. D., F. R. S., Joint Lecturer on General Anat. and Phys., in the Med. School of St. Bartholomews Hosp. London. Elements of Histology. In one handsome pocket size 12mo. volume of 360 pages, with 181 illustrations. Limp cloth, red edges, $1.50. Just ready. (See Students' Series of Manuals, page 5.) Although an elementary work, it is by no means superficial or incomplete, for the author presents in concise language nearly all the fundamental facts regarding the microscopic structure of tissues. The illustrations are numerous and excellent. We commend Dr. Klein's Elements most heartily to the student. Medical Record, Dec. 1, 1883. PEPPER, A. J., M. B., M. S., F. R. C. S. f Surgeon and Lecturer at St. Mary's Hospital, London. Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, $2.00. Just ready. See Students' Series of Manuals, page 5. It is prepared especially to meet the requirements "--*" of the student, but contafns much of interest for the general practitioner. The author has succeeded admirably in putting the work forward in the most practical form, and he deserves great praise for the lucidity of style and brevity of descriptions. The illustrations are numerous and well selected. The arrangement is easy and natural. We would espe- cially recommend i't not only to students, but to all who wish a concise and clear exposition of some of the intricate problems of surgical pathology. Nash- ville Journal of Medicine and Surgery, Jan. 1884. GREEN, T. HENRY, M. !>., Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, etc. Pathology and Morbid Anatomy. Fifth American from the sixth enlarged and revised English edition. In one very handsome octavo volume of about 350 pages, with about 150 fine engravings. In press. SCHAFER'S PRACTICAL HISTOLOGY. In one handsome royal 12mo. volume of 308 pages, with 40 illustrations. GLUGE'S ATLAS OF PATHOLOGICAL HISTOL- OGY. Translated by JOSEPH LF.IDT, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, and descriptive letter-press. Cloth, $4.00. 14 HENRY C. LEA'S Sox &. Co.'s PUBLICATIONS Practice of Med. FLINT. AUSTIN. JT. D.. Prof, of Otf Principles and Practice of Med. and of Clin. Med. in Betlevue Hospital Medical College, \. 7. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. With an Appendix on the Researches of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of Phthisis. Fifth edition, revised and largely rewritten In one large and closely -printed octavo volume of 1160 pages. Cloth, $5.50* ; leather. $6.50; very handsome half Russia, raised bands, $7. Just ready. Koch's discovery of the bacillus of tubercle gives promise of being the greatest boon ever conferred by science on humanity, surpassing even vaccination in its benefits to mankind. In the appendix to his work, Professor Flint deals with the subject from a practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog- nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard work will be more than ever a necessity to the physician who duly appreciates the re- sponsibility of his calling. We cannot conclude this notice without express- ! won its way in England, that no inconsiderable teg our admiration for this volume, which is cer- < number of 'men use it alone in the study of pure tainly one of the standard text-bookson medicine ; medicine; and we can say of it that it is' in every and we may safely affirm that, taken altogether, it way adapted to serve, not only as a com plete guide. exhibits a fuller and wider acquaintance with re- but also as an ample instructor in the science and cent pathological inquiry than an similar work practice of medicine. The style of Dr. Flint is with which we are acquainted, and it shows its an- j always polished and engaging. ' The work abounds thor to be possessed of the rare faculties of clear in perspicuous explanation, an . .. liable exposition, thoughtful discrimination and sound ' judgment London Lancet, July 23, 1881. In a word, we do not know of any similar work which is at once so elaborate and so concise, so full and yet so accurate, or which in every part leaves give this, the fifth edition, anything more than a upon the mind the impression of its being the pro- i passing notice. But even the most cursory exami- dact of an author richly stored with the fruits of l nation shows that it is, practically, much more clinical observation, and an adept in the art of con- than a revised edition; it is, in fact, rather a new raying them clearly and attractively to others. work throughout. This treatise will undoubtedly American Journal of Medical Science*, April, 188L continue to hold the first place in the estimation A well-known writer and lecturer on medicine of American physicians and students. No one of recently expressed an opinion, in the highest de- j our medical writers approaches Professor Flint in gree complimentary of the admirable treatise of clearness of diction, breadth of view, and, what we Dr. Flint, and in eulogizing it, he described it ac- regard of transcendent importance, rational esti- cnrately as "readable and reliable." No text-book mate of the value of remedial agents. It is thor- ia more calculated to enchain the interest of the oughly practical, therefore pre-eminently the. book student, and none better classifies the multitudi- for American readers. St. Louis Clin. Bee,, Mar. '81. nous subjects included in it. It has already so far , text-book of medicine. London Med'ca-' y., F. It. C. P., Physician and Joint Lecturer on Medicine at St. Thomaf Hospital. A Treatise on the Practice of Medicine. Second American edition, revised by the Author. Edited, with additions, by JAMES H. HrrcHrssox, M.D., physician to the Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. Cloth," $5.00 ; leather, $6.00; very handsome half Russia, raised bands, $6.50. author in following the latest growth of medical The second edition of this excellent work, like the first, has received the benefit of Dr. Hntchin- ?-:.'- ar.:. Mta*, v y -.*;. :::.::.- i :.s.-~- -f -ii-.~a.-~ which are peculiar to this country are indicated, and thus a treatise which was intended for British practitioners and students is made more practically useful on this side of the water. We seeno reason to modify the high opinion previously expressed with regard to Dr. Bnstowe's work, except by add- ing our appreciation of the careful labors of the - - - "'- science. Boston Medical and Surgical Journal, Feb. BO. The reader will find every conceivable subject connected with the practice of medicine ably pre- sented, in a style at once clear, interesting and concise. The additions made by Dr. Hutchinson are appropriate and practical, and greatly add to its usefulness to American readers. Buffalo Med- ical and Surgical Journal, March, 1880. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Practice of Med. 15 REYNOLDS, J. RUSSELL, 31. D., Professor of the Principles and Practice of Medicine in University College, London. A System of Medicine. With notes and additions by HENRY HARTSHORJTE, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Kussia, raised bands, $6.50. Per set, cloth, $15 ; sheep, $18 ; half Kussia, $19.50. Sold only by tub&riptian. VOLUME I. Contains GENERAL DISEASES and DISEASES OF THE NERVOUS SYSTEM. VOLUME II. Contains DISEASES OF KESPIRATORY and CIRCULATORY SYSTEMS. VOLUME III. Contains DISEASES OF THE DIGESTIVE, BLOOI^LAXDULAR, URINARY, RE- PRODUCTIVE and CUTANEOUS SYSTEMS. Reynolds' SYSTEM OF MEDICINE, recently completed, has acquired, since the first ap- pearance of the first volume, the well-deserved reputation of being the work in which modern British medicine is presented in its fullest and most practical form. This could , scarce be otherwise in view of the fact that it is the result of the collaboration of the lead- ing minds of the profession, each subject being treated by some gentleman who is regarded as its highest authority. All the leading schools in Great Britain have contributed their best men, in generous rivalry, to build up this monument of medical science. That a work conceived in such a spirit and carried out under such auspices should prove an indis- pensable treasury of facts and experience, suited to the daily wants of the practitioner, was- inevitable ; and the success which it has enjoyed in England, and the reputation which it has acquired on this side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. Its large size and high price having kept it beyond the reach of many practitioners in this country who desire to possess it, a demand has arisen for an edition at a price which shall render it accessible to all. To meet this demand the present edition has been under- taken. The five volumes and five thousand pages of the original have, by the use of a smaller type and double columns, been compressed into three volumes of over three thousand pages, clearly and handsomely printed, and offered at a price which renders it one of the cheapest works ever presented to the American profession. But not only is the American edition more convenient and lower priced than the Eng- lish ; it is also better and more complete. Some years having elapsed since the appearance of a portion of the work, additions were required to bring up the subjects to the existing con- dition of science. Some diseases, also, which are comparatively unimportant in England, require more elaborate treatment to adapt the articles devoted to them to the wants of the American physician ; and there are points on which the received practice in this country differs from that adopted abroad. The supplying of these deficiencies has been undertaken by HENRY HARTSHORNE, M. D., late Professor of Hygiene in the University of Pennsyl- vania, who has endeavored to render the work fully up to the day, and as useful to the American physician as it has proved to be to his English brethren. The number of illus- trations has also been largely increased, and no effort spared to render the typographical execution unexceptionable in every respect. There is no medical work which we have in times past more frequently and fully consulted when perplexed by doubts as to treatment, or by having unusual or apparently inexplicable symp- toms presented to us. than "Reynolds' System of Medicine." It contains just that kind of Informa- tion which the busy practitioner frequently finds himself in need of. In order that any deficiencies may be supplied, the publishers have committed the preparation of the book for the press to Dr. Henry Hartshorne. whose judicious notes distrib- uted throughout the volume afford abundant evi- dence of the thoroughness of the revision to which he has subjected it. American Journal of the Med- ical Sciences, Jan. 1880. so concise and thorough, and withal so lucid and trustworthy. In that branch of medicine in which the rank and file of the profession are mainly in- terested, vit, the practical part, therapeutics, Bey- nolds, without intending any invidious com pan" stands pre-eminent. The therapeutics of the Eng- lish correspond more closely than those of any- other country with those of this country, and the American editor of Reynolds' has brought this branch up to the most advanced American stand- ard. JtfidMjan Medical JYw, Feb. 15, 1880. These three volumes are a whole library in and of themselves. As works of reference they are destined to be for many years regarded as the very highest authority on medical subjects. Certainly no work with which we are acquainted guage is scarcely adequate to express the actual has ever been given to the English-reading profes- value to general practitioners of such a system of sion which treats of so many diseases in a manner medicine as this. Gnei*Kati Lament amd CKmie. ^ THOMAS, M. D., Late Ph>/gician in Ordinary to the Quean. Lectures on the Principles and Practice of Physic. Delivered at King's College, London. A new American from the fifth English edition, revised and enlarged. Edited, with additions, and 190 illustrations, by HENRY HARTSHORNE, A. M n M. D, late Professor of Hygiene in the University of Pennsylvania. In two large and handsome octavo volumes, containing 1840 pages. Cloth, $9.00 ; leather, $11.00. WOODBVRY, FRANK, M. !>., Physician to the German Hospital, Philadelphia; late Ckief Assistant to tke Jtedital Cftmcm Jtfer- s&n College Hospital, etc. A Handbook of the Principles and Practice of Medicine. For the use of Students and Practitioners. In one royal 12mo. volume, with illustrations. Preparing. A CENTURY OF AMERICAN* MEDICrJTE, 17761876. By Drs. E. H. CLAMI, H. J. BICKI.OW, S. D. GKOSS, T. G. THOXAS, and J. S. Btuaxes. In one 12mo. rolume of 370 pages. Cloth, f2J&. 16 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Clinical Med., etc. FOTHERGILL, J. M., M. D., Edin., M. K. C. P., Lond., Asst. Phys. to the West Lond. Hosp., Asst. Phj/s. to the City of Lond. Hasp., etc. The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- peutics. Second edition, revised and enlarged. In one very handsome octavo volume of 651 pages. Cloth, $4.00 ; very handsome half Russia, raised bands, $5.50. A book which can give correctly and interest- ingly, as well as scientifically, the method of prescribing and the rationale of the best thera- peutics in the treatment of disease, is manifestly just the work which each physician desires. It is not extravagant eulogy to say that the physician will find in this work of Fothergill the guide which he seeks for his therapeutics; for not only is the treatment which he .seeks already indicated herein, but the rationale of the treatment is as clearly ex- plained. Gaillard's Med. Journ., Sept. 1880. The author merits the thanks of every well-edu- cated physician for his efforts toward rationalizing the treatment of diseases upon the scientific basis impress of a master-hand; and while the work is thoroughly scientific in every particular, it presents to the thoughtful reader all the charms and beau- ties of a well-written novel. No physician can well afford to be without this valuble work, for its originality makes it fill a niche in medical litera- ture hitherto vacant. Nashville Journ. of Med. and Surg., Oct. 1880. The junior members of the profession will find it a work that should not only be read but care- fully studied. It will assist them in the proper selection and combination of therapeutical agents best adapted to each case and condition, and enable them to prescribe intelligently and success- of physiology. Every chapter, every line, has the j fully. St. Louis Courier of Medicine, Nov. 1880. FLINT, AUSTIN, M. D. Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In one large and hand- some octavo volume of 799 pages. Cloth, $4.50 ; leather, $5.50 ; half Kussia, $6.00. It is here that the skill and learning of the great clinician are displayed. He has given us a store- house of medical knowledge, excellent for the stu- dent, convenient for the practitioner, the result of a long life of the most faithful clinical work, col- lected by an energy as vigilant and systematic as untiring, and weighed by a judgment no less clear than his observation is close. Archives of Medicine, Dec. 1879. To give an adequate and useful conspectus of the extensive field of modern clinical medicine is a task of noordinary difficulty; but to accomplish this con- sistently with brevity and clearness, the different subjects and their several parts receiving the attention which, relatively to their importance, I in the intervals between the^iaily rounds of visits, medical opinion claims for them, is still more diffi- j since he can in a few minutes refresh his memory cult. This task, we feel bound to say, has been i or learn the latest advance in the treatment of of advanced medicine in this country as that of the author of two works of great merit on special subjects, and of numerous papers exhibiting much originality and extensive research. The Dublin Journal, Dec. 1879. The great object is to place before the reader the latest observations and experience in diagnosis and treatment. Such a work is especially valuable to students. It is complete in its special design, and yet so condensed that they can by its aid keep up with the lectures on practice without neglect- ing other branches. It will not escape the notice of the practitioner that such a work is most valu- able in culling points in diagnosis and treatment val: executed with more than partial success by Dr. Flint, whose name is already familiar to sti by Dr. udents diseases which demand his instant attention. Cincinnati Lancet and Clinic, Oct. 25, 1879. By the Same Author. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 pages. Cloth, $1.38. FINLATSON, JAMES, M. D., Editor, Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine. With Chapters by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephens on Diseases of the Female Organs; Dr. Robertson on Insanity; Dr. Gemmell on Physical Diagnosis ; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case-taking, Family History and Symptoms of Disorder in the Various Systems. In one handsome 12mo. volume of 546 pages, with 85 illustrations. Cloth, $2.63. This is one of the really useful books. It is at- tractive from preface to the final page, and ought to be given a place on every office table, because it contains in a condensed form all that is valuable in semeiology and diagnostics to be found in bulkier volumes; and because of its arrangement and complete index it is unusually convenient for quick reference in any emergency that may come upon the busy practitioner. N. C. Med. Journ., Jan. 1879. FENWICK, SAMUEL, M. D., Assistant Physician to the London Hospital. The Student's Guide to Medical Diagnosis. From the third revised and enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 87 illustrations on wood. Cloth, $2.25. TANNER, THOMAS HAWKES, M. D. A Manual of Clinical Medicine and Physical Diagnosis. Third American from the second London edition. Revised and enlarged by TIUJUKY Fox, M. D., Phy- sician to the Skin Department in University College Hospital, London, etc. In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. STURGES' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome 12mo. volume of 127 pages. Cloth, $1.25. DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; being a collection ol the Clinical Lectures delivered in the Medical Ward of Mercy Hospital, Chicago. Edited by FRANK H. DAVIS, M. D. Second edition. In one royal 12mo. volume of 287 pages. Cloth, $1.75. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Electric., Prac., etc. 17 RICHARDSON, B. W., M.A., M.D., LL. D., F.R.S., F.S.A. Fellow of the Royal College of Physicians, London. Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5 ; very handsome half Russia, raised bands, $5.50. Just ready. presented can be found so systematically arranged and intelligently presented. The 'Sanitarian, March, 1884. This is a book that will surely find a place on the table of every progressive physician. To the medical profession, whose duty is quite as much to prevent as to cure disease, the book will be a boon. Boston Medical and Surfjical Journal, Mar. G, 1884. The treatise contains a vast amount of solid, valu- able hygienic information. Medical and Surgical Reporter, Feb. 23, 1884. Though this work has been written with spe- cial reference to non-professional readers, it excels any other book which has before fallen under our observation on the subject of which it treats, as a text-book for the medical reader. It comprehends the nature, causes and prevention of disease from a strictly scientific standpoint. The American publishers have done the medical profession a valuable service in laying it before them as a work that contains much with which every phy- sician should be familiar. There is no other work In the language in which the information here Excerpt from Contents. I. Disease as a Unity, with a variety of Phenomena. The Preventive Scheme of Medicine. General Diseases of Mankind. 1. Constitutional Diseases. 2. Local Diseases. 3. Diseases from Natural Accidents, Lightning Sunstroke Starvation Poisons Venoms Poisonous Food Pregnancy. II. Acquired Diseases of Artificial Origin ; Phenomena and Course. 1. Acquired Diseases from Inorganic and Organic Poisons, Tea Coffee Alcohol Tobacco Soot Gases. 2. Acquired Diseases from Physical Agencies, Mechanical and General, Dusts Pressure on Lungs Concussions and Shocks Muscular Overwork and Strain Acquired Deformities Physical Injuries Surgical Operations. 3. Acquired Diseases from Mental Agencies, Moral, Emotional and Habitual. Diseases from Mental Shock, from Moral Contagion, Tarantism Suicide, from Hysterical Emotion, from Passion, from Habits of Life Insomnia Dementia Sloth Luxury Secret Immorality. III. 1. Origins and Causes of Disease, Congenital, Hereditary or Constitutional Causes ; Atmospheric and Climatic Causes ; Parasitic Causes, Bacteria Bacilli Spirilla Trichinae; Zymotic Causes; Industrial and Accidental Causes; Social and Psychical Causes; Senile Degenerative Causes. 2. Preventions of Disease. Prevention of Hereditary or Constitutional Diseases, Personal Rules for Preg- nancy, Infancy, Adolescence, Maturity ; Prevention of Atmospheric and Climatic Diseases ; of Parasitic Diseases, Personal Rules ; of Zymotic Diseases, Contagion Drainage Isolation of Sick Water and Milk Supply Hospitals Registration Vaccination Other Inoculations Legislation ; Prevention of Industrial Diseases Lead Poisoning Dusts Gases, etc. ; Prevention of Social and Psychical Diseases, Warming and Ventila- tion Light Water the Bed-room Bread Abattoirs Schools Sepulturer Drunken- ness ; Prevention of Senile Disease. BARTHOLOW, ROBERTS, A. M., M. &., LL. J>., Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. Second edition. In one very handsome octavo volume of 292 pages, with 109 illustrations. Cloth, 2.50. The second edition of this work following so soon upon the first would in itself appear to be a sufficient announcement; nevertheless, the text A most excellent work, addressed by a practi- tioner to his fellow-practitioners, and therefore thoroughly practical. The work now before us has been so considerably revised and condensed, ; lias the exceptional merit of clearly pointing out and so much enlarged by the addition of new mat- | where the benefits to be derived from electricity ter, that we cannot fail to recognize a vast improve- ment upon the former work. The author has pre- pared his work for students and practitioners for must come. It contains all and everything that the practitioner needs in order to understand in- telligently the nature and laws of the agent he is those who have never acquainted themselves with making use of, and for its proper application in the subject, or, having done so, find that after a j practice. In a condensed, practical form, it pre- time their knowledge needs refreshing. We think I seuts to the physician all that he would wish to he has accomplished this object. The book is not too voluminous, but is thoroughly practical, sim- ple, complete and comprehensible. It is, more- over, replete with numerous illustrations of instru- ments, appliances, etc. Medical Record, November 15, 1882. remember after perusing a whole library on medical electricity, including the results of the latest in- vestigations. It is the book for the practitioner, and the necessity for a second edition proves that it has been appreciated by the profession. Physi- cian and Surgeon, Dec. 1882. HABERSHON, S. O., M. D., Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London. On the Diseases of the Abdomen ; Comprising those of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illustrations. Cloth, $3.50. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one octavo volume of 238 pages. Cloth, $2.00. CHAMBERS' MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- some octavo volume of 302 pp. Cloth, $2.75. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With additions by D. F. CONDIB, M.D. 1 vol. 8vo., pp. 603. Cloth, $2.50. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. Cloth, 2.50. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 YOl. 8vo., pp. 493. Cloth, $3.50. 18 HENRY 0. LEA'S SON & Co.'s PUBLICATIONS Throat, Lungs, etc. SEILER, CARL, M. D., Lecturer on Larynyoscopy in the University of Pennsylvania.. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume of 294 pages, with 77 illustrations. Cloth, $1.75. Just ready. Dr. Seller's book is a clear, concise, practical exposition of the subject, such as only a master of it could have written. It is better suited to the wants of advanced students and voung physicians than any other at present in the "hands of the pro- fession. American Practitioner, Aug, 1883. Dr. Seller's treatise contains all the essentials of the knowledge of the important localities com- pressed into a small space and put together by one of the ablest of American specialists. To stu- dents and others this book can be recommended as one of the best and most generally useful. Canada Medical and Surgical Journal, July, 1883. BROWNE, LENNOX, F. R. C. 8., Edin., Senior Surgeon to the Central London Throat and Ear Hospital, etc. The Throat and its Diseases. Second American from the second English edi- tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, designed and executed by the Author. In one very handsome imperial octavo volume of about 350 pages. Preparing. FLINT, AUSTIN, M. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand- some royal 12mo. volume of 240 pages. Cloth, $1.63. Just ready. This practical and justly popular manual is con- Yeniently divided into eight chapters, and the student is gradually led up from a general con- sideration of physical signs in health and disease to the differential diagnosis of diseased conditions by a knowledge of these physical signs. As in his courses of practical instruction, so in this book the author's plan is to simplify the subject as much as possible; to consider the distinguishing haracteristics of different physical signs as de- termined by analysis, and as based particularly on the variations in the intensity, pitch and quality of sounds; to impress the facts upon the student and reader that the significance of physical signs relates to certain physical conditions, and that close study of the physical conditions in health and disease is a sine qua non of success in both diagnosis and treatment. The Medical News, April 28, 1883. By the Same Author. Physical Exploration of the Lungs by Means of Auscultation and Percussion. Three lectures delivered before the Philadelphia County Medical Society, 1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. By the Same Author. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. By the Same Author. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. Cloth, $3.50. By the Same Author. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, $4. GROSS, S. D., M.D., LL.D., &.C.L. Oxon.. LL.D. Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. FULLER ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Di- agnosis, Symptoms and Treatment. From the second and revised English edition. In one octavo volume of 475 pages. Cloth, $3.50. BLADE ON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Second and revised edition. In one 12mo. vol., pp. 158. Cloth, $1.25. LECTURES ON THE STUDY OF FEVER. By A. HUDSON, M. D., M. R. I. A. In one octavo volume of 308 pages. Cloth, $2.50. SMITH ON CONSUMPTION; its Early and Reme- diable Stages. 1 vol. 8vo., pp. 253. $2.25. LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 pages. Cloth, $3.00. WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edi- tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. STOKES' LECTURES ON FEVER. Edited by John William Moore, M. D., F. K. Q. C. P. In one octavo volume of 280 pages. Cloth, $2.00. A TREATISE ON FEVER. By ROBERT D. LYONS, K. C. C. In one 8 vo. vol. of 354pp. Cloth, $2.25. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. With an analysis of one thousand cases to exemplify its duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological and Therapeutical Relations. In two large and hand- some octavo volumes of 1468 pp. Cloth, $7.00. CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS, by C. HANBFIKI.D JONES, M. D. Second American edition. In one hand- some octavo volume of 340 pages. Cloth, $3.25. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Nerv. and Ment. Dis.,etc. 19 HAMILTON, ALLAN McLANE, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, BlackweWs Island, N. Y., and at the Out- Patients' Department of the New York Hospital. Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. We are glad to welcome a second edition of so use- ful a work as this, in which Dr. Hamilton has suc- ceeded in condensing into convenient limits the most important of the recent developments in re- gard to diseases of the nervous system. Of recent years nervous pathology has attained to such im- Eortanoe as to necessitate very careful description a special works, and among these this volume must take a high place. This volume is on the whole excellent, and is devoid of that spirit of plagiarism which we have unfortunately seen too much of in certain recent English works on nervous diseases. Edinburgh Medical Journal, May, 1882. When thefirstedition of this good book appeared we gave it our emphatic endorsement, and the present edition enhances our appreciation of the book and its author as a safe guide to students of clinical neurology. One of the best and most critical of English neurological journals, Brain, has characterized this book as the best of its kind in any language, which is a handsome endorsement from an exalted source. The improvements in the new edition, and the additions to it, will justify its purchase even by those who possess the Alienist and Neurologist, April, 1882. ily its old. TUKE, DANIEL HACK, M. D., Joint Author of The Manual of Psychological Medicine, etc. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. New edition. Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with two colored plates. Cloth, $3.00. Just ready. The immense power of the imagination, both in causing and curing disease, has been recognized from the infancy of medical science, but the practical application of this fact has hitherto been chiefly confined to charlatans and lias always been one of the secrets of their frequent success. To rescue this invaluable therapeutic agent from unmerited ill- repute, and to obtain its recognition as a legitimate instrument of the regular profession, is briefly the object of this volume. Not only is the work thus one of high importance to the practitioner who desires to utilize all the resources of his art, but in its authentic revelations of the fantastic interaction of man's dual nature, it rivals in some of its narratives the most interesting creations of fiction. The favor with which the work has hitherto been received will be enhanced by the labor bestowed in the revision as well as by the addition of two carefully prepared colored plates. CLOUSTON, THOMASl$^M^I>., F. It. C. P., L. R. C. S., Lecturer on Mental Diseases in the University of Edinburgh. Clinical Lectures on Mental Diseases. With an Appendix, containing an Exhaustive Summary of the Laws in Force in the United States upon the Commit- ment and Confinement of the Insane. By CHARLES F. FOLSOM, M. D., Assistant Pro- fessor of Mental Diseases, Medical Department of Harvard University. In one hand- some octavo volume of about 600 pages, illustrated with woodcuts and eight lithographic plates, four of which are beautifully colored. Cloth, $4. In a few days. At the author's request, Professor Folsom has critically examined this work, and has specially prepared for it the appendix on United States laws relating to the insane. The work will thus afford American practitioners a complete and trustworthy guide in medical and legal questions arising from cases of mental disease. We should say that to have read a book like Dr. Clouston's lectures, and mastered his definitions, must make a man as well prepared as books can make him, to recognize the principal symptoms of insanity. We feel that every statement has been weighed, considered and viewed in many different relations. The student gets all the in- formation about the symptoms and treatment of insanity in well considered words. It ma5 r be viewed as a proof of the thoroughness of the work and the originality of the author, that so much care has been taken with the therapeutics of insanity. Dr. Clouston has sought out and thought out, by observation and experiment, methods of treatment suitable to the various forms of insanity, which constitute, perhaps, the most valuable features of the book. Edinburgh Medical Journal, Feb. 1884. PLAYFAIR, W. S., M. D., F. K. C. J. The Systematic Treatment of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, $1.00. Just ready. The book is well worth perusal, and will repay anyone for the time spent in its careful study, in- asmuch as it will lead to a better understanding of the management of those betes noirs of the physi- cian, nerve prostration and hysteria. Details are given of the manner of carrying out the treatment, to which are added the histories of a number of cases illustrative of the method and its results. An appendix contains a description of the method of performing massage, which is clear and con- cise. New Orleans Medical and Surgical Journal, May, 1883. MITCHELL, S. WEIH, M. !>., Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phtta., etc. Lectures on Diseases of the Nervous System; Especially in Women. Second edition. In one very handsome 12mo. volume of about 250 pages. Preparing. ' Blandford on Insanity and its Treatment: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane, by ISAAC RAY, M. D. In one rery handsome octavo volume. 20 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Surgery, GROSS, S. D., M. L>., LL. D., D. C. L. Oxon., LL. D. Cantab. , Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- printed imperial octavo" volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, 15 ; half Russia, raised bands, $16. The work as a whole needs no commendation. ! fully maintains the reputation the work has ac- Many years ago it earned for itself the enviable rep- quired. It has become a complete and systematic utati'on of the leading American work on surgery, book of reference alike for the student and the and it is still capable of maintaining that standard. , practitioner. The London Lancet, Jan. 27, 1883. The reason for this need only be mentioned to be We regard Gross' System of Surgery not only as appreciated. The author lias always been calm a singularly rich storehouse of scientific informa- and judicious in his statements, has based his con- i tion, but as marking an epoch in the literary liis- clusions on much study and personal experience, j torv of surgery. The present edition has received has been able to grasp'his subject in its entirety, j the" most careful revision at the hands of the emi- and, above all, has conscientiously adhered to nent author himself, assisted in various instances truth and fact, weighing the evidence, pro and con, accordingly. A considerable amount of new material has been introduced, and altogether the by able specialists in various branches. AH depart- ments of the vast and ever-increasing literature of the science have been drawn upon for their most distinguished author has reason to be satisfied recent expressions. The late advances made in that he has placed the work fully abreast of the surgical practice have been carefully noted, such state of our knowledge. Med. Record, Nov. 18, 1882. as the recent developments of Listerism and the We have purposely abstained from comment or j improvements in gyn:ecological operations. In criticism of the book before us. It has formerly been noticed more than once in our columns, and it every respect the work reflects lasting credit on American medicalliterature. Medical and Surgical is enough now to remark that the present edition Reporter. Nov. 11. 1882. ASHHURST, JOHN, Jr., M. D., Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. The Principles and Practice of Surgery. Third edition, enlarged and re- vised. In one large and handsome octavo volume of 1060 pages, with 555 illustrations. Cloth, $6 ; leather, $7 ; very handsome half Russia, raised bands, $7.50. Dr. Ashhurst's Surgery is a condensed treatise j the work must be its best claim for continued covering the whole domain of the science in one j popularity with students and practitioners. In manageable volume. The present edition has had j fact, in this respect it is without an equal in any a thorough revision. The novelties in surgical j language. In the present edition many novelties practice and the recent observations in surgical in surgical practice are introduced, many modifi- science have been incorporated, but the size of the cations of previous statements made, and several volume has not been materially increased. The new illustrations added. Med. author's arrangement is perspicuous, and his language correct and clear. An excellent index closes the work, and on the whole we consider it the best system of surgery in one volume which could be named as the product of an American author. Medical and Surgical Reporter, Oct. 28, '82. The author, long known as a thorough student of surgery, and one of the most accomplished scholars in the country, aims to give in this work "a condensed but comprehensive description of the modes of practice now generally employed in the treatment of surgical affections, with a plain exposition of the principles upon which these modes of practice are based." In this he has so well succeeded that it will be a surprise to the reader to know how much practical knowledge ex- tending over such a wide range of research is com- ding ov ssed in a volume of this size. This feature of ec., Nov. 18, 1882. It treats in a very thorough and satisfactory manner all the subjects in the various departments of surgery. The medical student and general prac- titioner of medicine will find it admirably adapted to their wants, the former as a text-hook, and the latter as a most valuable work of reference when he wishes to refresh his mind and obtain the latest information on any subject of surgery. While there are no omissions or abridgements of any description or discussions essential for imparting a thorough knowledge of any principle or practice, yet unnecessary details and lengthy statements of views of various writers are excluded. In revising his work for a third edition, the author has spared no pains to render it worthy of a continuance of the favor with which it has heretofore been re- ceived. We predict an increasing demand for the work. Cincinnati Medical News, Nov., 1882. pre: GIBNEY, V. JR., M. D. Surgeon to the Orthopedic Hospital, New York, etc. Orthopaedic Surgery. For the use of Practitioners and Students. In one hand- some octavo volume, profusely illustrated. Preparing. ROBERTS, JOHN B., A. M., M. D^ Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. The Principles and Practice of Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 pages, with many illustrations. Preparing. BELLAMY, EDWARD, F. R. C. S. Operative Surgery. In active preparation. See Students' Series of Manuals, page 5. 8TIMSON, LEWIS A., B. A., M. D., Prof, of Pathol. Anat. at the Univ. of the City of New York, Surgeon and Curator to Sellevue Hasp. A Manual of Operative Surgery. In one very handsome royal 12mo. volume of 477 pages, with 332 illustrations. Cloth, $2.50. This volume is devoted entirely to operative sur- gery, and is intended to familiarize the student with the details of operations and the different modes of performing them. The work is hand- somely illustrated, arid the descriptions are clear and well^drawn. It is a clever and useful volume ; every student should possess one. This work does away with the necessity of pondering over larger works on surgery for descriptions of opera- tions, as it presents in a nutshell what is wanted by the surgeon without an elaborate search to find it. Maryland Medical Journal, August, 1878. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Surgery. 21 BRYANT, THOMAS, F. R. C. 8., Surgeon to Guy's Hospital, London. The Practice of Surgery. Third American from the third and revised English edition. Thoroughly revised and much improved, by JOHN B. EGBERTS, A. M., M. D., Lecturer on Anatomy and Operative Surgery in the Philadelphia Academy of Surgery. In one large and very handsome imperial octavo volume of 1009 pages, with 735 illustra- tions. Cloth, 6.50; leather, $7.50; very handsome half Russia, raised bands, $8.00. Without freighting his book with multiplied de- | plans of treatment, etc., to make the surgeon who tails and wearying descriptions of allied methods follows the text successful in his diagnosis and of procedure, lie is ample enough for reference on all the departments of surgery, not omitting such strict specialties as dental, Ophthalmic, military, orthopaedic and gynaecological surgery. Some of these chapters are written by specialists in these respective brandies, and all are amply sufficient for anyone not himself aiming at special practice. The labors of the American editor deserve un- qualified praise. His additions to the author's text are numerous, judicious and germane. They add very distinctly to the value of the original treatise, and give a more equitable illustration of the part taken by American surgeons than the author was able to do. Medical and Surgical Re- porter, Feb. 12, 1881. It is the best of all the one-volume works on sur- gery of recent date for the ordinary surgeon, con- taining enough of pathology, accurate description of surgical diseases and "injuries, well-devised treatment in any case in which success can be se- cured, according to the present state of the sur- gical art. Virginia Medical Monthly, May, 1881. It is a work especially adapted to the wants of students and practitioners. It affords instruction in sufficient detail for a full understanding of sur- gical principles and the treatment of surgical dis- eases. It embraces in its scope all the diseases that are recognized as belonging to surgery, and all traumatic injuries. In discussing these it has seemed to be the aim of the author rather to pre- sent the student with practical information, and that alone, than to burden his memory with the views of different writers, however distinguished they might have been. In this edition the whole work has been carefully revised, much of it has been rewritten, and important additions have been made to almost every chapter. Cincinnati Medical Xeii'i, Jan. 1881. ERICHSEN, JOHN E., F. R. 8. 9 F. R. C. 8., Professor of Surgery in University College, London, etc. The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- eases and Operations. Specially revised by the Author from the eighth and enlarged English edition. In two large and beautiful octavo volumes of about 2000 pages, illus- trated with about 900 engravings on wood. Preparing. A few notices of the previous edition are appended. His polished, clear style, his freedom from pre- judice and hobbies, his unsurpassed grasp of his subject and vast clinical experience, qualify him admirably to write a model text-book. When we not only in this country, but in Great Britain. That it is able to hold its ground is abundantly proven by the thoroughness with which the pres- ent edition has been revised, and by the large wish, at the least cost of time, to learn the most of i amount of valuable material that has been added. a topic in surgery, we turn, by preference, to his work. It is a pleasure, therefore, to see that the appreciation of it is general. Medical and Surgical Reporter, Feb. 2, 1878. For the past twenty years Erichsen's Surgery has maintained its place as the leading text-book, Aside from this, one hundred and fifty new illus- trations have been inserted, including quite a number of microscopical appearances of patholo- gical processes. So marked is this change for the etter that the work almost appears as an entirely new one. Medical Record, Feb. 23, 1878. ESMARCH, Dr. FRIEDRICH, Professor of Surgery at the University of Kiel, etc. Early Aid in Injuries and Accidents. Five Ambulance Lectures. Trans- lated by H. R. H. PRINCESS CHRISTIAN. In one handsome small 12mo. volume of 109 pages, with 24 illustrations. Cloth, 75 cents. Just ready. The excellent little handbook by Dr. Esmarch ] organization of the human body, illustrated by may be referred to by all for clear, safe and practi- clear, suitable diagrams. The second teaches how cal directions and instructions for rendering the right kind of aid until the doctor arrives, in the event of the numerous injuries that are liable to happen in a family or neighborhood in the circum- stances of daily life. The manual is earnestly and justly commended for its excellence and clear- ness, and especially for the minuteness and extent to give judicious help in ordinary injuries contu- sions, wounds, haemorrhage and poisoned wounds. The third treats of first aid in cases of fracture and of dislocations, in sprains and in burns. Next, the methods of affording first treatment in cases of frost-bite, of drowning, of suffocation, of loss of consciousness and of poisoning are described; of its practical details. Harpers' Magazine, Aug., i and the fifth lecture teaches how injured persons 1883. j may be most safely and easily transported to their The course of instruction is divided into five j homes, to a medical man, or to a hospital. The sections or lectures. The first, or introductory i illustrations in the book are clear and good. Medv~ lecture, gives a brief account of the structure and \ cal Times and Gazette, Nov. 4, 1882. DRVITT, ROBERT, M. R. C. 8., etc. The Principles and Practice of Modern Surgery. From the eighth London edition. In one Svo. volume of 687 pages, with 432 illus. Cloth, $4 ; leather, $5. SARGENT ON BANDAGING AND OTHER OPERA- TIONS OF MINOR SURGERY. New edition, with a Chapter on military surgery. One l'2mo. volume of 383 pages, with/187 cuts. Cloth, S1.7A. MILLER'S PRINCIPLES OF SURGERY. Fourth j American from the third Edinburgh edition. In i one Svo. vol. of 088 pages, with 340 illustrations. Cloth, 83.75. MILLER'S PRACTICE OF SURGERY. Fourth and revised American from the last Edinburgh edition. In one large Svo. vol. of 682 pages, with 364 illustrations. Cloth, 83.75. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by JOHN NEILL, M. D. In one Svo. vol. of 784 pp. with 316 illus. Cloth, $3.75. COOPER'S LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one Svo. vol. of 767 pages. Cloth, $2.00. SKEY'S OPERATIVE SURGERY. In one vol. 8va of 661 pages, with 81 woodcuts. Cloth, $3.25. GIBSON'S INSTITUTES AND PRACTICE OP SURGERY. Eighth edition. In two octavo Tola, of 965 pages, with 34 plates. Leather 86.50. 22 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Surgery. HOLMES, TIMOTHY, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. A System of Surgery ; Theoretical and Practical. IN TREATISES BY VARIOUS AUTHORS. AMERICAN EDITION, THOROUGHLY REVISED AND RE-EDITED by JOHN H. PACKARD, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. In three large and very handsome imperial octavo volumes containing 3137 double- columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per volume, cloth, $6.00 ; leather, $7.00 ; half Eussia, $7.50. Per set, cloth, $18.00 ; leather, 21.00 ; half Russia, $22.50. Sold only by subscription. VOLUME I. contains GENERAL PATHOLOGY, MORBID PROCESSES, INJURIES IN GEN- ERAL, COMPLICATIONS OF INJURIES AND INJURIES OF REGIONS. VOLUME II. contains DISEASES OF ORGANS OF SPECIAL SENSE, CIRCULATORY SYS- TEM, DIGESTIVE TRACT AND GENITO-URINARY ORGANS. VOLUME III. contains DISEASES OF THE RESPIRATORY ORGANS, BONES, JOINTS AND MUSCLES, DISEASES OF THE NERVOUS SYSTEM, GUNSHOT WOUNDS, OPERATIVE AND MINOR SURGERY, AND MISCELLANEOUS SUBJECTS (including an essay on HOSPITALS). This great work, issued some years since in England, has won sucli universal confi- dence wherever the language is spoken that its republication here, in a form more thoroughly adapted to the wants of the American practitioner, has seemed to be a duty owing to the profession. To accomplish this, each article has been placed in the hands of a gentleman specially competent to treat its subject, and no labor has been spared to bring each one up to the foremost level of the times, and to adapt it thoroughly to the practice of the country. In certain cases this has rendered necessary the substitution of an entirety new essay for the original, as in the case of the articles on Skin Diseases and on Diseases of the Absorbent System, where the views of the authors have been superseded by the advance of medical science, and new articles have therefore been prepared by Drs. Arthur . Van Harlingen and S. C. Busey, respectively. So also in the case of Anaesthetics, in the use of which American practice differs from that of England, the original has been supple- mented with a new essay by J. C. Reeve, M. D. The same careful and conscientious revision has been pursued throughout, leading to an increase of nearly one-fourth in matter, while the series of illustrations has been nearly trebled, and the whole is presented as a complete exponent of British and American Surgery, adapted to the daily needs of the working practitioner. In order to bring it within the reach of every member of the profession, the five vol- umes of the original have been compressed into three by employing a double-columned royal octavo page, and in this improved form it is offered at less than one-half the price of the original. It is printed and bound to match in every detail with Reynolds' System of Medi- cine. The work will be sold by subscription only, and in due time every member of the profession will be called upon and offered an opportunity to subscribe. The authors of the original English edition are men of the front rank in England, and Dr. Packard has been fortunate in securing as his American coadjutors such men as Bartholow, Hyde, Hunt, Conner, Stimson, Morton, Hodgen, Jewell and Great credit is due to the American editor and his co-laborers for revising and bringing within easy reach of American surgeons a work which has been received with such universal favor on the other side of the Atlantic as Holmes' System of their colleagues. As a whole, the work will be | Surgery. With regard to the mechanical execu- solid and substantial, and a valuable addition to tion of the work, neither pains nor money seem the library of any medical man. It is more wieldly to have been spared by the publishers. Med. and and more useful than the English edition, and with Surg. Reporter, Sept. 14, 1881. its companion work "Reynolds' System of Medi- In the rev ;,,j on O f the work for the American cine "-will well represent the present state of our < ^ e no ? on y has prov s?on been mad science One who is familiar with those two works : recognition of the .dvMJces made in our knowledge will be fairly well furnished head-wise and hand- ^,,^ ; 2 *i,<> * ,, Q O,. O c,;,, u= ^t ,xi;f,- wise. The Medical News, Jan. 7, 1882. This work is cyclopaedic in character, and every subject is treated in an exhaustive manner. It is especially designed for a reference book, which during the ten years since its first publication, g te but also for a presentation of the variations in practice which characterize American surgery and distinguish it from that of Great Britain. The work is one which we take pleasure in com- every practising surgeon should have under hand mending to the notice of our readers as an ency- in cases which require more than ordinary knowl- ' clopeedia of surgical knowledge and practice. edge. Chicago Med. Journ. and Exam., Feb. 1882. ! St. Louis Courier of Medicine, Nov. 1881. HAMILTON, FRANK H., M. D., LL. D., Surgeon to Betlevue Hospital, New York. A Practical Treatise on Fractures and Dislocations. Sixth edition, thoroughly revised and much improved. In one very handsome octavo volume of 909 pages, with 352 illustrations. Cloth, $5.50; leather, $6.50 ; half Russia, raised bands, $7.00. The only complete work on its subject in the English tongue, and indeed it may now be said to be the only work of its kind in any tongue. It would require an exceedingly critical examination to detect in it any particulars in which it might be improved. The work is a mon- ument to American surgery ; and will long serve to keep green the memory of its venerable author. Michigan Medical News, Nov. 10, 1881. work in his own or any language on fractures and dislocations. Lond. Med. Times and Gaz. Nov. 19, '81. The work as a whole is one of the very few medical books of American origin that are every- where accorded a standard character. Its sub- ject-matter unavoidably comes home to every general practitioner as a branch of our art in which he cannot afford to neglect the fullest and most practical information of such a character as it Dr. Hamilton is the author of the best modern I and it alone furnishes. IV. Y. Med. Jour., March.'Sl. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Frac., Disloc., Oplithal. 23 STIMSON, LEWIS A., B. A., M. D., Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Ouarator to Bellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc. A Practical Treatise on Fractures. In one very handsome octavo volume of 598 pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75. The author gives in clear language all that the | The author has given to the medical profession practical surgeon need know of the science of in this treatise on fractures what is likely to be- iractures, their etiology, symptoms, processes of union, and treatment, according to the latest de- velopments. On the basis of mechanical analysis come a standard work on the subject. It is certainly not surpassed by any work written in the English, or, for that matter, any other language. The au- the author accurately and clearly explains the j thor tells us in a short, concise andTcomprehensive ciinical features of fractures, and by the same manner, all that is known about his subject. There method arrives at the proper diagnosis snd rational treatment. A thorough explanation of the patho- is nothing scanty or superficial about it, as in most other treatises ; on the contrary, everything is thor- logieal anatomy and a careful description of the i ough. The chapters on repair o"f fractures and their various methods of procedure make the book full treatment show him not only to be a profound stu- of value for every practitioner. The diction is | dent, but likewise a practical surgeon andpatholo- simple, clear and vivid. Wherever desirable, brief ] gist. His mode of treatment of the different fract- clinical histories are introducted, which, being : ures is eminently sound and practical. Weconsider rgeon in lull pr_ an especial attraction of the book. Centralblatt < Surgical Journal, March, 1883. fur Chirurgie, May 19, 1883. WELLS, J. SOELBERG^F. R. , c7^~ Professor of Ophthalmology in King's College Hospital, London, etc. A Treatise on Diseases of the Eye. Fourth American from the third London edition. Thoroughly revised, with copious additions, by CHARLES S. BULL,, M. D., Surgeon and Pathologist to the New York Eye and Ear Infirmary. In one large and very hand- some octavo volume of 822 pages, with 257 illustrations on wood, six colored plates, and selections from the Test-types of Jaeger and Snellen. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands 3 $6.50. Just ready. The present edition appears in less than three i plete work on diseases of the eye in the English years since the publication of the last American ] language, will find in this treatise the fulfilment edition, and yet, from the numerous recent inves- of that desire. Dr. Bull's additions to the volume tigations that have been made in this branch of may be taken as a brief but very excellent resuini medicine, many changes and additions have been required to meet the present scope of knowledge upon this subject. A critical examination at once shows the fidelity and thoroughness with which the editor has accomplished his part of the work. The illustrations throughout are good. This edi- tion can be recommended to all as a complete treatise on diseases of the eye, than which proba- bly none better exists. Medical Record, Aug. 18, '83. This magnificent work is par excellence the standard work of the times on the important sub- jects of which it treats. It is absolutely necessary for the physician to have an acquaintance with the pathology and therapeutics of the eye. From no source can he more accurately derive this needed knowledge than from the volume before us. Medical and Surgical Reporter, August 4, 1883. Anyone desirous of obtaining the most com- of the progress made in ophthalmology during the past ten years. It is no exaggeration to sajr that there are few more readable books in medi- cine than this; certainly no medical library can be considered complete without it. Canada Medi- cal and Surgical Journal, November, 1883. The issue of a fourth American edition of this work within three years of the third, shows how favorably it has been received by the medical pro- fession at large. We must congratulate the editor on his clearness and conciseness in laying down rules for treatment and the proper remedies to be used in every case. This work must be pro- nounced the most complete text-book on the sub- ject, and merits careful perusal by the student as well as the practitioner, while to the specialist it will be found an easy and faithful book of refer- ence. Cincinnati Lancet and Clinic, August 18, 1838. NETTLESHIP, EDWARD, F. R. C. S., Ophthalmic Surg. and Lect. on Ophth. Surg. at St. Thomas' Hospital, London. The Student's Guide to Diseases of the Eye. New edition. With a chap- ter on the Detection of Color-Blindness, by WILLIAM THOMSON, M. D., Ophthalmologist to the Jefferson Medical College. In one royal 12mo. volume of 416 pages, with 138 illustrations. Cloth, $2.00. Just ready. This admirable guide bids fair to become the favorite textrbook on ophthalmic surgery with stu- dents and general practitioners. It bears through- out the imprint of sound judgment combined with vast experience. The illustrations are numerous j and well chosen. This book, within the short com- pass of about 400 pages, contains a lucid exposition of the modern aspect of ophthalmic science. Medical Record, June 23, 1883. This work is essentially a student's manual of ophthalmology, and the favor with which it has been received shows its real value and the appre- ciation by the profession of its intrinsic merits. Dr. Thomson has added a Chapter on Color-Blind- ness, on which subject his extensive investigations are well known. With this valuable addition the Vinnlr HAnnrrms t.hp mncjf valuable cmiHft t.o Hisp.a^fiR BROWNE, EDGAR A., Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. How to Use the Ophthalmoscope. Being Elementary Instructions in Oph- thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 pages, with 35 illustrations. Cloth, $1.00. LAVVSON ON INJURIES TO THE EYE, ORBIT AND EYELIDS: Their Immediate and Remote Effects. 8 vo., 404 pp., 92 illus. Cloth, $3.50. LAURENCE AND MOON'S HANDY BOOK OF OPHTHALMIC SURGERY, for the use of Prac- titioners. Second edition. In one octavo vol- ume of 227 pages, with Go illust. Cloth, $2.75. CARTER'S PRACTICAL TRPUTISE ON DISEAS- ES OF THE EYE. Edited by JOHN GMBH, M.D. In one handsome octavo volume. 24 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Otol., Dent.,Urin. Dis. POLITZER, ADAM, Imperial- Royal Prof, of Aural Therap. in the Univ. of Vienna. ' A Text-Book of the Ear and its Diseases. Translated, at the Author's re- quest, by JAMES PATTERSON CASSELLS, M. D., M. E. C. S. In one handsome octavo vol- ume of 800 pages, with 257 original illustrations. Cloth, $5.50. Just ready. Professor Politzer's well-known reputation as one of the first authorities on diseases of the ear will 'ead the reader to expect something more than an ordinary text-book in a work that bears his name, and he will not be disappointed. The anatomy, physiology, pathology, therapeutics and bibfi- ography of the ear are so ably and thoroughly pre- sented, that he who has carefully read this imposing has ever appeared, systematic without being too diffuse on obsolete subjects, and eminently prac- tical in every sense. The anatomical descriptions of each separate division of the ear are admirable, and profusely illustrated by woodcuts. They are followed imme_diately by the physiology of the section, and this again by the pathological physi- ology, an arrangement which serves to keep up the volume can feel sure that very little of interest or I interest of the student by showing the direct ap- value in the past or present of aural surgery has t plication of what has preceded to the study of dis- eseaped him. .4m. Jour. oftheMed. Sciences, July, I ease. The whole work can be recommended as a 1883. | reliable guide to the student, and an efficient aid The work itself we do not hesitate to pronounce ' to the practitioner in his treatment. Boston Med- the best upon the subject of aural diseases which [ cal and Surgical Journal, June 7, 1883. BURNETT, CHARLES H., A. M., M. D., Aural Surg. to the Presb. Hosp., Surgeon-in-charge of the Infir.for Dis. of the Ear, Philadelphia. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. New edition. In one handsome octavo volume of about 700 pages, with about 100 illustrations. A notice of the previous edition is appended. The medical profession will welcome this work on otology, which presents clearly and con- cisely its present aspect, whilst clearly indicating the direction in which further researches can be most profitably carried on. L)r. Burnett has pro- duced a work which, as a text-book, stands facile prinreps in our language. To the specialist the work is of the highest value. Edinburgh Med.Jour., Aug. '78. COLEMAN, A., L. R. C. P., F. R. C. S., Exam. L. D. S., Senior Dent. Surg. and Lect. on Dent. Surg. at St. Bartholomew's Hosp. and the Dent. Hosp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by THOMAS C. STELLWAGEX, M. A., M. D., D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. This volume deserves to rank among the most ] deserves a place in the library of every dentist, important of recent contributions to dental litera- I Dental Cosmos, May, 1882. ture. Mr. Coleman has presented his methods of ! It should be in the possession of every practi- practice, for the most part, in a plain and concise manner, and the work of the American editor has been conscientiously performed. He has evidently labored to present his convictions of the best mode's of practice for the instruction of those commenc- ing a professional career, and he has faithfully en- deavored to teach to others all that he has acquired tioner in this country. The part devoted to first and second dentition and irregularities in the per- manent teeth is fully worth the price. In fact, price should not be considered in purchasing such a work. If the money put into some of our so-called standard text-books could be converted into such publications as this, much good would result. by his own observation and experience. The book | Southern Dental Journal, May, 1882. GROSS, S. !>., M. D., LL. D., D. C. L., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised by SAMUEL W. GROSS, M. D., Surgeon to the Philadelphia Hospital. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. For reference and general information, the phy- sual advantage of being easily comprehended by sician or surgeon can find no work that meets their the reasonable and practical manner in which the necessities more thoroughly than this, a revised various subjects are systematized and arranged, edition of an excellent treatise. Replete with hand- Atlanta Medical Journal, Oct., 1876. some illustrations and good ideas, it has the unu- ROBERTS, WILLIAM, M. L>., Lecturer on Medicine in the Manchester School of Medicine, etc. A Practical Treatise on Urinary and Renal Diseases, including Uri- nary Deposits. Fourth American from the fourth London edition. Illustrated by numerous engravings. In one large and handsome octavo volume. Preparing. THOMPSON, SIR HENRY, Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Fistulas. From the third English edition. In one volume of 359 pages, witk 47 cuts and 3 plates. Cloth, $3.50. BASHAM ON RENAL DISEASES : A Clinical I one 12mo. vol. of 304 pages, with 21 illustration* Guide to their Diagnosis and Treatment. In | Cloth, $2.00. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Venereal Dis., etc. 25 BUMSTEAD, F. J., and M. D., LL. D., Late Professor of Venereal Diseases at the College of Physicians and Surgeons, -ZVete York, etc. TAYLOR, R. W., A. M., M. D., Surgeon to Charity Hospital, A'ew York, Prof, of Venereal and Skin Diseases in the University oj Vermont, Pres. of the Am. Dermatoloyical Ass'n. The Pathology and Treatment of Venereal Diseases. Including the results of recent investigations upon the subject. Fifth edition, revised and largely re- written, by Dr. Taylor. In one large and handsome octavo volume of about 898 pages with 139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75 ; leather, $5.75 ; very handsome half Russia, $6.25. Excerpt from the Preface to the Fifth Edition. In this edition I have carefully revised the text, and, when necessary, have changed and modified it, and I have endeavored to bring it up to our present state of knowledge in all particulars. Much new matter will be found relating to therapeutics, and a chapter on syphilis and marriage has been appended. This admirable book is undoubtedly the best | known that it would be superfluous here to pass in book 011 the subject which has appeared on this (review its general or special points of excellence, side of the Atlantic, and one of the best which lias The verdict of the profession has been passed; it appeared anywhere. As years have rolled by it has reached successive editions, constantly assimi- lating the conclusions of scientific investigations all over the world, and never falling behind the advance guard of its own department. This last edition keeps up tne reputation which its prede- cessors req sps up uired. It comes revised, added to and improved. It is in every way admirable, a credit to its authors and a credit to its publishers. The Medical News, Dec. 22, 1883. The character of this standard work is so well has been accepted as the most thorough and com- plete exposition of the pathology and treatment of venereal diseases in the language; admirable as a model of clear description, an exponent of sound pathological doctrine, and a guide for rational and successful treatment, it is an ornament to the medi- cal literature of this country. The additions made to the present edition are eminently judicious, from the standpoint of practical utility" Journal of Cutaneous and \'e.nereal Diseases, Jan. 1884. CORNIL, V., Professor to the Faculty of Medicine of Paris, and Phj/sician to the Lourcine Hospital. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially revised by the Author, and translated with notes and additions by J. HENRY C. SIMES, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, ana J. WILLIAM WHITE, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. Just ready. The anatomical and histologies! characters of the hard and soft sore are admirably described. The multiform cutaneous manifestations of the disease are dealt with histologically in a masterly way, as we should indeed expect them to be, and the accompanying illustrations are executed carefully and well. The various nervous lesions which are the recognized outcome of the syphilitic dyscrasia are treated with care and consideration. Syphilitic, epilepsy, paralysis, cerebral syphilis and loeomotor ataxia are subjects full of interest; and nowhere in the whole volume is the clinical experience of the author or the wide acquaintance of the translators with medical literature more evident. The anat- omy, the histology, the pathology and the clinical features of syphilis are represented in this work in their best, most practical and most instructive form, and no one will rise from its perusal without the feeling that his grasp of the wide and impor- tant subject on which it treats is a stronger and surer one. The London Practitioner, Jan. 1882. GROSS, SAMUEL W., A. M., M. L>., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. Second edition, thoroughly revised. In one very hand- some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50. Just ready. The author of this monograph is a man of posi- j tive convictions and vigorous style. This is justi- fied by his experience and by his study, which has gone hand in hand with his experience. In regard i to the various organic and functional disorders of the male generative apparatus, he has had ex- ceptional opportunities for observation, and his book shows that he has not neglected to compare his own views with those of other authors. The result is a work which can be safely recommended to both physicians and surgeons as a guide in the treatment of the disturbances it refers to. It is the best treatise on the subject with which we are acquainted. The Medical iVeics, Sept. 1, 1883. Be- e Agrees, sides the subjects embraced in the title, which ar treated of in their various forms and degrees, spermatorrhoea and prostatorrhcea are also fully considered. The work is thoroughly practical in character, and will be especially useful to the general practitioner. Medical. Record, Aug. 18, 1883. CULLERIER, A., & BTJMSTEAD, F. J., M.D., LL.D., Surgeon to the H6pital du Midi. Late Professor of Venereal Diseases in the College of Physiciant and Surgeons, 2>eui York. An Atlas of Venereal Diseases. Translated and edited by FREEMAN J. BUM- STEAD, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Strongly bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. HILL ON SYPHILIS AND LOCAL CONTAGIOUS i FORMS OF LOCAL DISEASE AFFECTING DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. I PRINCIPALLY THE ORGANS OF GENERA- LEE'S LECTURES ON SYPHILIS AND SOME | TION. In one 8vo. vol. of 246 pages. Cloth, $2.25. 26 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Diseases of Skin. HYDE, J. NEVINS, A. M., M. D., Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. In one handsome octavo volume of 570 pages, with 66 beautiful and elab- orate illustrations. Cloth, $4.25 ; leather, $5.25. Just ready. The author has given the student and practi- tioner a work admirably adapted to the wants of each. We can heartily commend the book as a valuable addition to our literature and a reliable ciau in active practice. In dealing with these questions the author leaves nothing to the pre- sumed knowledge of the reader, but enters thor- oughly into the most minute description, so that guide to students and practitioners in their studies I one is not only told what should be done under and practice. Am. Journ. of Med. Sci., July, 1883. i given conditions but how to do it as well. It is Especially to be praised are the practical sug- | therefore in the best sense "a practical treatise." gestions as'to what may be called the common- j That it is comprehensive, a glance at the index sense treatment of eczema. It is quite impossible will show. Maryland Medical Journal, July 7, 1883. to exaggerate the judiciousness with which the Professor Hyde has long been known as one of formulae for the external treatment of eczema are the most intelligent and enthusiastic representa- selected, and what is of equal importance, the full f tives of dermatology in the west. His numerous and clear instructions for their use. London Medi- contributions to the literature of this specialty cal Times and Gazette, July 28, 1883. \ have gained for him a favorable recognition as a The work of Dr. Hyde will be awarded a high i careful, conscientious and original observer. The position. The student of medicine will find it ; remarkable advances made in our knowledge of peculiarly adapted to his wants. Notwithstanding , diseases of the skin, especially from the stand- the extent of the subject to which it is devoted^ point of pathological histology and improved yet it is limited to a single and not very large vol- methods of treatment, necessitate a revision of ume, without omitting a proper discussion of the | the older text-books at short intervals in order to topics. The conciseness of the volume, and the bring them up to the standard demanded by the setting forth of only what can be held as facts will march of science. This last contribution of Dr. also make it acceptable to general practitioners. ' Hyde is an effort in this direction. He has at- Cincinnati Medical Xews, Feb. 1883. i tempted, as he informs us, the task of presenting The aim of the author has been to presenttohis > in a condensed form the results of the latest pb- readers a work not only expounding the most servation and experience. A careful examination modern conceptions of his subject, but presenting ] of the work convinces us that he has accomplished what is of standard value. He has more especially '. his task with painstaking fidelity and with a cred- devoted its pages to the treatment of disease, and ; itable result. Journal of Cutaneous and Venereal by his detailed descriptions of therapeutic meas- Diseases, June, 1883. ures has adapted them to the needs of the physi- FOX, iled descriptions of therapeutic meas- Diseases, June, 1883. lapted them to the needs of the physi- T., M.D., F.It. C. P., and FOX, T. C., B.A., M.R. C.S., Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the University College Hospital, London. Westminster Hospital, London. An Epitome of Skin Diseases. With Formulae. For Students and Prac- titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume of 238 pages. Cloth, $1 .25. Just ready. The third edition of this convenient handbook manual to lie upon the table for instant reference, calls for notice owing to the revision and expansion Its alphabetical arrangement is suited to this use, for all one has to know is the name of the disease, and here are its description and the appropriate treatment at hand and ready for instant applica- tion. The present edition has been very carefully one which we can strongly recommend, not only j revised and a number of new diseases are de- to students but also to practitioners who require a i scribed, while most of the recent additions to which it has undergone. The arrangement of skin diseases in alphabetical order, which is the method of classification adopted in this work, becomes a positive advantage to the student. The book is compendious summary of the present state of dermatology. British Medical Journal, July 2, 1883. We cordially recommend Fox's Epitome'to those whose time is limited and who wish a handy dermal therapeutics find mention, and the formu- lary at the end of the book has been considerably augmented. The Medical News, December, 1883. MORRIS, MALCOLM, M. D., Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London. Skin Diseases ; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor- bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo. volume of 316 pages, with illustrations. Cloth, $1.75. To physicians who would like to know something j for clearness of expression and methodical ar- about skin diseases, so that when a patient pre- rangement is better adapted to promote a rational sents himself for relief they can make a correct i conception of dermatology a branch confessedly diagnosis and prescribe a rational treatment, jve | difficult and perplexing to the beginner. St. Louis unhesitatingly recommend this little book of Dr. Morris. The affections of the skin are described in a terse, lucid manner, and their several charac- teristics so plainly set forth that diagnosis will be easy. The treatment in each case is such as the experience of the most eminent dermatologists ad- vises. Cincinnati Medical News, April, 1880. This is emphatically a learner's book; for we can safely say, that in the whole range of medical literature there is no book of a like scope which Courier of Medicine, April, 1880. The writer has certainly given in a small compass a large amount of well-compiled information, and his little book compares favorably with any other which has emanated from England, while in many points he has emancipated himself from the stub- bornly adhered to errors of others of his country- men. There is certainly excellent material in the book which will well repay perusal. Boston Med. and Surg. Journ., March, 1880. WILSON, ERASMUS, F. R. S. The Student's Book of Cutaneous Medicine and Diseases of the Skin. In one handsome small octavo volume of 535 pages. Cloth, $3.50. HILLIER, THOMAS, M. D., Physician to the Skin Department, of University College, London. Handbook Of Skin Diseases ; for Students and Practitioners. Second Ameri- can edition. In one 12mo. volume of 353 pages, withjplates. Cloth, $2.25. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Dis. of Women. 27 AN AMERICAN SYSTEM OF GYN&COLOGY. A System of Gynaecology, in Treatises by Various Authors. In two handsome octavo volumes , richly illustrated. In active preparation. LIST OF CONTRIBUTORS. FORDYCE BARKER, M. D., CHARLES CARROLL LEE, M. D., ROBERT BATTEY, M. D., WILLIAM T. LUSK, M. D., SAMUEL C. BUSEY, M. D., MATTHEW D. MANN, M. D., HENRY F. CAMPBELL, M. D., ROBERT B. MAURY, M. D., BENJAMIN F. DAWSON, M. D., C. D. PALMER, M. D., WILLIAM GOODELL, M. D., WILLIAM M. POLK, M. D., HENRY F. GARRIGUES, M. D., TIIADDEUS A. REAMY, M. D., SAMUEL W. GROSS, M. D., A. D. ROCKWELL, M. D., JAMES B. HUNTER, M. D., ALBERT H. SMITH, M. D., WILLIAM T. HOWARD, M. D., R. STANSBURY SUTTON, A. M., M. D., A. REEVES JACKSON, M. D., T. GAILLARD THOMAS, M. D., EDWARD W. JENKS, M. D., CHARLES S. WARD, M. D.. WILLIAM H. WELCH, M. D. THOMAS, T. GAILLARD, M. D., Professor of Diseases of Women in the College of Physicians and Surgeons, JV. }". A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Kussia, raised bands, $6.50. The words which follow " fifth edition" are in I vious one. As a book of reference for the busy this case no mere formal announcement. The j practitioner it is unequalled. Boston Medical and alterations and additions which have been made are ; Surgical Journal, April 7, 1880. both numerous and important. The attraction ! It has been enlarged and carefully revised. It is and the permanent character of this book lie in i a condensed encyclopaedia of gynaecological medi- the clearness and truth of the clinical descriptions J cine. The style of arrangement, the masterly of diseases; the fertility of the author in thera- | manner in which each subject is treated, and the peutic resources and the fulness with which the honest convictions derived from probably the details of treatment are described; the definite I largest clinical experience in that specialty of any character of the teaching: and last, but not least. | in this country, all serve to commend it in the the evident candor which pervades it. We would \ highest terms to the practitioner. Nashville Jour. also particularize the fulness with which the his- | of Med. and Surg., Jan. 1881. tory of the subject is gone into, which makes the j That the previous editions of the treatise of Dr. book additionally interesting and gives it value as | Thomas were thought worthy of translation into a work of reference. London Medical Times and Gazette, July 30, 1881. The determination of the author to keep his book foremost in the rank of works on gynaecology German, French, Italian and Spanish, is enough to give it the stamp of genuine merit. At home it has made its way into the library of every obstet- rician and gynecologist as a safe guide to practice. is most gratifying. Recognizing the fact that this No small number of additions have been made to can only be accomplished by frequent and thor- ! the present edition to make it correspond to re- ougn revision, he lias spared no pains to make the ; cent improvements in treatment. Pacific Medical present edition more desirable even than the pre- i and Surgical Journal, Jan. 1881. ED IS, ARTHUR W.^M^J^Lond., F.R. C. P., M. R. C. S., Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. The Diseases of Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. The greatest pains have been taken with the sections relating to treatment. A liberal selection of remedies is given for each morbid condition, It is a pleasure to read a book so thoroughly good as this one. The special qualities which are conspicuous are thoroughness in covering the whole ground, clearness of description and con- the strength, mode of application and other details ciseness of statement. Another marked feature of being fully explained. The descriptions of gynse- the book is the attention paid to the details of \ cological manipulations and operations are full, many minor surgical operations and procedures, as, for instance, the use of tents, application of leeches, and use of hot water injections. These are among the more common methods of treat- ment, and yet very little is said about them in many of the text-books. The book is one to be warmly recommended especially to students and general practitioners, who need a concise but com- plete resume of the whole subject. Specialists, too, will find many useful hints in its pages. Boston Med. and Surg. Journ., March 2, 1882. clear and practical. Much care has also been be- stowed on the parts of the book which deal with diagnosis we note especially the pages dealing with the differentiation, one from another, of the different kinds of abdominal tumors. The prac- titioner will therefore find in this book the kind of knowledge he most needs in his daily work, and he will be pleased with the clearness and fulness of the information there given. The Practitioner, Feb. 1882. BARNES, ROBERT, M. D., F. R. C. P., Obstetric Physician to St. Thomas' Hospital, London, etc. A Clinical Exposition of the Medical and Surgical Diseases of Women. In one handsome octavo volume, with numerous illustrations. New edition. Preparing. CHADWICK, JAMES R., A. M., M. J>. A Manual of the Diseases Peculiar to Women. In one handsome royal 12mo. volume, with illustrations. Preparing. WEST, CHARLES, M.D. Lectures on the Diseases of Women. Third American from the third Lon- don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 28 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Dis. of Women, Midwfy. EMMET, THOMAS AI)DIS, M. !>., LL. &., Surgeon to the Woman's Hospital, New York, etc. The Principles and Practice of Gynaecology ; For the use of Students and Practitioners of Medicine. Second edition. Thoroughly revised. In one large and very handsome octavo volume ot 879 pages, with 133 illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, $6.50. ical and surgical history more novel and useful. No gynaecological treatise has appeared which contains an equal amount of original and useful matter; nor does the med of America include a book The tabular and statistical information which it contains is marvellous, both in quantity and accu- racy, and cannot be otherwise than invaluable to future investigators. It is a work which demands not careless reading but profound study. Its value as a contribution to gynsecology is, perhaps, greater than that of all previous literature on the subject combined. Chicago Medical Gazette, April 5, 1880. In no country of the world has gynaecology re- j Feb. 21, 1880. ceived more attention than in America. It is, then, with a feeling of pleasure that we welcome a work on diseases of women from so eminent a gymecologist as Dr. Emmet. The work is essen- tially clinical, and leaves a strong impress of the author's individuality. To criticise, with the care it merits, the book throughout, would demand far more space than is at our command. In parting, we can say that the work teems with original ideas, fresh and valuable methods of practice, and is written in a clear and elegant style, worthy of the literary reputation of the country of Longfellow and Oliver Wendell Holmes. British Med. ^ournal, DUNCAN, J. MATTHEWS, M.D., LL. D., F. It. S. E., etc. Clinical Lectures on the Diseases of Women; Delivered in Saint Bar- tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. They are in every way worthy of their author; ', stamp of individuality that, if widely read, as they indeed, we look upon them as among the most certainly deserve to be, they cannot fail to exert a valuable of his contributions. They are all upon matters of great interest to the general practitioner. Some of them deal with subjects that are not, as a rule, adequately handled in the text-books ; others of them, while bearing upon topics that are usually treated of at length in such works, yet bear such a wholesome restraint upon the undue eagerness with which many young physicians seem bent upon following the wild teachings which so infest the gynaecology of the present day. Jf. Y. Medical Journal, March, 1880. GUSSEROW, A., Professor of Midwifery and the Diseases of Children at the University of Berlin. A Practical Treatise on Uterine Tumors. Specially revised by the Author, and translated with notes and additions by EDMUND C. WENDT, M. D., Pathologist to the St. Francis Hospital, N. Y., etc., and revised by NATHAN BOZEMAN, M. D., Surgeon to the Woman's Hospital of the State of New York. In one handsome octavo volume, with about 40 illustrations. Preparing. HODGE, HUGHL., M. D., Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. On Diseases Peculiar to Women ; Including Displacements of the Uterus. Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 pages, with original illustrations. Cloth, $4.50. By the Same Author. The Principles and Practice of Obstetrics. Illustrated with large litho- graphic plates containing 159 figures from original photographs, and with numerous wood- cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in cloth, $14.00. * * * Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. TARNIER, 8., and CHANTREUIL, G. A Treatise on the Art of Obstetrics. Translated from the French. In two large octavo volumes, richly illustrated. RAMSBOTHAM, FRANCIS H., M. J). The Principles and Practice of Obstetric Medicine and Surgery; In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With additions by W. V. KEATING, M. D., Professor of Obstetrics, etc., in the Jefferson Medical College of Philadelphia. In one large and handsome imperial octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. ASHWELL'S PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Third American from the third and revised London edition. In one 8vo. vol., pp. 520. Cloth. $3.50. AND OTHER DISEASES PECULIAR TO WO- MEN. In one 8vo. vol. of 4C4 pages. Cloth, S.'.oO. MEIGS ON THE NATURE, SIGNS AND TREAT- MENT OF CHILDBED FEVER. In one Svo. CHURCHILL ON THE PUERPERAL FEVER I volume of 346 pages. Cloth, $2.00. HENRY C. LEA'S SON & Co.'s PUBLICATIONS Midwifery. 29 PLAYFAIR, W. S., M. D., F. R. C. P., Professor of Obstetric Medicine in King's College, London, etc. A Treatise on the Science and Practice of Midwifery. Third American edition, revised by the Author. Edited, with additions, by ROBERT P. HARRIS, M. D. In one handsome octavo volume of 659 pages, with 183 illustrations. Cloth, $4; leather, $5 ; half Russia, $5.50. The medical profession has now the opportunity j all details not necessary for a full understanding of adding to their stock of standard medical works of the subject are omitted. Cincinnati Meaical one of the best volumes on midwifery ever pub- : Neics, Jan., 1880. lished. The subject is taken up with a master, it certainly is an admirable exposition of the hand. The part devoted to labor in all its various science and practice of midwifery. Of course the presentations, the management and results, is ad- additions made by the American editor, Dr. R. P. mirably arranged, and the views entertained will Harris, who never utters an idle word, and whose be found essentially modern, and the opinions ex- studious researches in some special departments pressed trustworthy. The work abounds with plates, illustrating Various obstetrical positions; they are admirably wrought, and afford great ~ isistance to the student. A. 0. Medical and Sur- of obstetrics are so well known to the profession, are of great value. The American Practitioner, April, 1880. The third edition so soon following the second gical Journal, March, 1880. ] shows that the good qualities of the book have been If inquired of by a medical student what work , recognized by the profession. The second Ameri- on obstetrics we should recommend for him, par j can has been'exhausted before the second English various subjects is concise and plain. While the j here being furnished with the latest work upon all discussions and descriptions are sufficiently elabo-] subjects pertaining to obstetrics. Am. Journal of rate to render a very intelligible idea of them, yet| Med. Sciences, April, 1880. KING, A. F. A., M. D., Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- sity, Washington, D. C., and in the University of Vermont, etc. A Manual of Obstetrics. New edition. In one very handsome 12mo. volume of 331 pages, with 59 illustrations. Cloth, $2.00. Just ready. A notice of the previous edition is appended. Though the book appears small externally, it I lent obstetric dictionary, and well suited to the stu- contains as complete a consideration of obstetric dent, it is also of value to the general practitioner, subjects as many larger volumes, and this is who often desires to find a resume of informatior chiefly owing to a directness of expression, and an upon a given subject. It will be of further value avoidance of repetition and of waste of words, to the latter, as, in our opinion, the author holds The author endeavors to place theories, causes of ' most sensible views on practical matters. The disease and methods of treatment in that order j book is admirably arranged for reference, being which, by weight of authority, they merit. His well paragraphed, with suitable sub-divisions, and excellent judgment has availed him well in this well indexed. American Journal of Obstetrics, Aug. effort. While, in one sense, the book is an excel- 1882. PARVIN, THEOPHILUS, M. &., LL. D., Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College. A Treatise on Midwifery. In one very handsome octavo volume of about 550 pages, with numerous illustrations. In press. BARNES, ROBERT, M. D., and FANCOTTRT, M. J)., Phys. to the General Lying-in Hasp., Land. . Obstetric Phys. to St. Thomas 1 Hasp., Lend. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For the Student and the Practitioner. The Section on Embryology contributed by Prof. Milnes Marshall. In two handsome octavo volumes, profusely illustrated. In press. BARNES, FANCOURT, M. D., Obstetric Physician to St. Thomas' Hospital, London. A Manual of Midwifery for Midwives and Medical Students. In one royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25. PARRY, JOHN S., M. D., Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. TANNER, THOMAS HAWKES, M. J). On the Signs and Diseases of Pregnancy. First American from the second English edition. In one handsome octavo volume of 490 pages, with 4 colored plates and 16 woodcuts. Cloth, $4.25. WINCKEL, F. A Complete Treatise on the Pathology and Treatment of Childbed. For Students and Practitioners. Translated, with the consent of the Author, from the second German edition, by JAMES READ CUADWICK, M. D. In one octavo volume of 484 pages. Cloth, $4.00. 30 HENRY C. LEA'S SON & Co.'s PUBLICATIONS Midwfy., Dis. Cliildn. LEISHMAN, WILLIAM, M. &., Regius Professor of Midwifery in the University of Glasgow, etc. A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. Third American edition, revised by the Author, with additions by JOHN S. PARRY, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, $6.00. The author is broad in his teachings, and dis- preparation of the present edition the author has cusses briefly the comparative anatomy of the pel- made such alterations as the progress of obstetri- vis and the mobility of the pelvic articulations. ; cal science seems to require, and we cannot but The second chapter is devoted especially to j admire the ability with which the task has been the study of the pelvis, while in the third the j performed. We consider it an admirable text- female organs of generation are introduced. ' book for students during their attendance upon The structure and development of the ovum are admirably described. Then follow chapters upon the various subjects embraced in the study of mid- wifery. The descriptions throughout the work are plain'and pleasing. It is sufficient to state that in this, the last edition of this well-known work, every recent advancement in this field has been brought forward. Physician and Surgeon, Jan. 1880. We gladly welcome the new edition of this ex- cellent text-book of midwifery. The former edi- tions have been most favorably received by the profession on both sides of the Atlantic. In the lectures, and have great pleasure in recommend- ing it. As an exponent of the midwiferv of the present day it has no superior in the English lan- guage. Canada Lancet, Jan. 1880. To the American student the work before us must prove admirably adapted. Complete in all its parts, essentially modern in its teachings, and with demonstrations noted for clearness and precision, it will gain in favor and be recognized as a work of standard merit. The work cannot fail to be popular and is cordially recommended. N. O. Med. and Surg. Journ., March, 1880. SMITH, J. LEWIS, M. D., Clinical Professor of Diseases of Children in the Bellerue Hospital Medical College, vY. 3". A Complete Practical Treatise on the Diseases of Children. Fifth edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, with illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised hands, $6. This is one of the best books on the subject with ; tioners on such questions as etiology, pathology, which we have met and one that has given us satisfaction on every occasion on which we ha\e consulted it, either as to diagnosis or treatment. It is now in its fifth edition and in its present form is a very adequate representation of tne subject it treats of as at present understood. The important subject of infant hygiene is fully dealt with in the early portion of the Dook. The great bulk of the work is appropriately devoted to the diseases of infancy and childhood. We would recommend any one in need of information on the subject to procure the work and form his own opinion on it, which we venture to say will be a favorable one. Dublin Journal of Medical Scienre, March, 1883. There is no book published on the subjects of which this one treats that is its equal in value to the physician. While he has said just enough to impart the information desired by general practi- prognosis, etc., he has devoted more attention to the diagnosis and treatment of the ailments which he so accurately; describes ; and such information is exactly what is wanted by the vast majority of 'family physicians." T'a. Me<1. Monthly, Feb. 1882. It is a pleasure to peruse such a work as the one before us, and as reviewers we have but one diffi- cultythere is but little to find fault with. The author understands what lie writes about from a practical acquaintance with the diseases incident to infancy and childhood, and also thoroughly comprehends their pathology and therapeutics. The work is full of original and practical remarks which will be particularly acceptable to the student and young physician; but at the same time we can with great sincerity commend it to the notice oi the profession in general. Edinb. Med. Jl., May, '82. In KEATING, JOHNM., M. D., Lecturer on the Diseases of Children at the University of Pennsylvania, etc. The Mother's Guide in the Management and Feeding of Infants, one handsome 12mo. volume of 118 pages. Cloth, $1.00. Works like this one will aid the physician im- i the employment of a wet-nurse, about the proper mensely, for it saves the time he is constantly giv- < food for a nursing mother, about the tonic effects ing his patients in instructing them on the sub- > of a bath, about the perambulator versus the nurses' jects here dwelt upon so thoroughly and prac- ] arms, and on many other subjects concerning tically. Dr. Keating has written a practical book, which the critic mi'ght say, "surely this is obvi- has carefully avoided unnecessary repetition, ana i ous," but which experience teaches us are exactly successfully instructed the mother in such details ' the things needed to be insisted upon, with the rich of the treatment of her child as devolve upon her. as well as the poor. London Lancet, January, 28 1882. He has studiously omitted giving prescriptions, j A book small in size, written in pleasant" style, in and instructs the mother when to call upon the language which can be readily understood by any doctor, as his duties are totally distinct from hers, mother, and eminently practical and safe; in fact American Journal, of Obstetrics, October, 1881. Dr. Keating has kept clear of the common fault of works of this sort, viz., mixing the duties of the mother with those proper to the doctor. There is the ring of common sense in the remarks about a book for which we have been waiting a long time, and which we can most heartily recommend to mothers as the book on this subject. New York Medical Journal and Obstetrical Rei'iew, Feb. 1882. WEST, CHARLES, M. D., Physician to the Hospital for Sick Children, London, etc. Lectures on the Diseases of Infancy and Childhood. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume of 686 pages. Cloth, $4.50 ; leather, $5.50. By the Same Author. On Some Disorders of the Nervous System in Childhood. 12mo. volume of 127 pages. Cloth, $1.00. In one small CONDIE'S PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, re- vised and augmented. In one octavo volume ol 779 pages. Cloth, $5.25 ; leather, $6.25. HENRIT C. LEA'S SON & Co.'s PUBLICATIONS Med. Juris., Miscel. 31 TIDY, CHARLES MEYMOTT, M. B., F. C. 8., Professor of Chemistry and oj Forensic Medicine and Public Health at the London Hospital, etc. Legal Medicine. VOLUME II. Legitimacy and Paternity, Pregnancy, Abor- tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- tavo volume of 529 pages. Cloth, $6.00; leather, $7.00. Just ready. VOLUME I. Containing 664 imperial octavo pages, with two beautiful colored plates. Cloth, $6.00 ; leather, $7.00. Recently issued. He whose inclinations or necessities lead him to Assume the functions of a medical jurist wants a book encyclopaedic in character, in which he may be reasonably sure of finding medico-legal topics discussed win judicial fairness, with sufficient completeness, and with due attention to the most recent advances in medical science. Mr. Tidy's work bids fair to meet this need satisfactorily. The fact that the very numerous illustrative cases are drawn from many sources, and are not limited, as in Casper's Handbook, to the author's own ex- perience, and the additional fact that they are brought down to a very recent date, give them, for purposes of reference, a very obvious value. Boston Medical and Surgical Journal, Feb. 8, 1883. TAYLOR, ALFRED 8., M. D., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by JOHN J. REESE, M. D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00; leather, $6.00; half Russia, raised bands, $6.50. The American editions of this standard manual j only have to seek for laudatory terms. American have for a long time laid claim to the attention of i Journal of the Medical Sciences, Jan. 1881. the profession in this country; and the eighth comes before us as embodying the latest thoughts and emendations of Dr. Taylor upon the subject to which he devoted his life with an assiduity and success which made him facile princeps among English writers on medical jurisprudence. Both the author and the book have made a mark too deep to be affected by criticism, whether it be censure or praise. In this case, however, we should fessions. Albany Law Journal, March 26, 1881. This celebrated work has been the standard au- thority in its department for thirty-seven years, both in England and America, in both the profes- sions which it concerns, and it is improbable that it will be superseded in many years. The work is simply indispensable to every physician, and nearly so to every liberally-educated lawyer, and we heartily commend the present edition to both pro- By the Same Author. The Principles and Practice of Medical Jurisprudence. Third edition. In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; leather, $12. Just ready. The revision of the third edition of this standard work has been most happily con- fided to a gentleman who was during fourteen years the colleague of the author, and who therefore is thoroughly conversant with the methods of thought which have everywhere gained for the book an exalted position as a work of reference. In its present form the work is the most complete exposition of Forensic Medicine in the English language. Taylor's Treatise at the hands of Dr. Stevenson has undergone a diminution of bulk with an in- crease of mass. This edition only asserts with stronger reason the allowed claims of the late Dr. Taylor's work to the first position among English books of its class. Including within its purview, as the subject does, something from every divi- sion of medical science, this exhaustive treatise will ever remain an invaluable collection of data. New York Medical Journal, Dec. 1, 1883. By the Same Author. Poisons in Relation to Medical Jurisprudence and Medicine. Third American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, $5.50 ; leather, $6.50. LEA, HENRY C. Superstition and Force : Essays on The Wager of Law, The Wager of Battle, The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volume of 552 pages. Cloth, $2.50. should not be most carefully studied ; and however well versed the reader may be in the science of jurisprudence, he will find much in Mr. Lea's vol- ume of which he was previously ignorant. The book is a valuable addition to the literature of so- This valuable work is in reality a history of civ- ilization as interpreted by the progress of jurispru- dence. . . In " Superstition and Force " we have a philosophic survey of the long period intervening between primitive barbarity and civilized enlight- enment. There is not a chapter in the work that cial science. Westminster Review, Jan. 1880. By the Same Author. ft Studies in Church History. The Rise of the Temporal Power Ben- efit of Clergy Excommunication. New edition. In one very handsome royal octavo volume of 605 pages. Cloth, $2.50. Just ready. primitive church traced with so much clearness, and with so definite a perception of complex or conflicting sources. The fifty pages on the growth The author is pre-eminently a scholar. He takes up every topic allied with the leading theme, and traces it out to the minutest detail with a wealth of knowledge and impartiality of treatment that compel admiration. The amount of information compressed into the book is extraordinary. In no other single volume is the development of the of the papacy, for instance, are admirable for co: ciseness and freedom from prejudice. Boston Traveller, May 3, 1883. 32 HENRY C. LEA'S SON & Co.'s MEDICAL AND SURGICAL PUBLICATIONS. INDEX TO CATALOGUE. American Journal of the Medical Sciences American System of Gynaecology . Allen's Anatomy .... ~*Ashhurst's Surgery .... Ashwell on Diseases of Women ^Attiield's Chemistry .... Barlow's Practice of Medicine Barnes' Midwifery .... Barnes on Diseases of Wpmen Barnes' System of Obstetric Medicine Bartholow on Electricity Basham on Renal Diseases . Bell's Comparative Physiology and Anatomy Bellamy's Operative Surgery Bellamy's Surgical Anatomy Blandford on Insanity Bloxam's Chemistry . Bowman's Practical Chemistry Bristowe's Practice of Medicine . Browne on the Ophthalmoscope Browne on the Throat Bruce's Materia Medica and Therapeutics Brunton's Materia Medica and Therapeutics Bryant's Practice of Surgery Buuistead on Venereal Diseases . Burnett on the Ear .... Carpenter on the Use and Abuse of Alcohol -Carpenter's Human Physiology . Carter on the Eye . . . Century of American Medicine Chadwick on Diseases of Women . Chambers on Diet and Regimen Churchill on Puerperal Fever Clarke and Lockwood's Dissectors' Manual Classen's Quantitative Analysis Cleland's Dissector .... Clouston on Insanity .... Clowes' Practical Chemistry Coats' Pathology .... Coleman's Dental Surgery . Coiidie on Diseases of Children . . / Cooper's Lectures on Surgery . . k Cornil and Ranyier's Pathological HistolOW Cornil on Syphilis . . . Cullerier's Atlas of Venereal Diseases Dalton's Human Physiology Daltou's Topographical Anatomy of the Brain Davis' Clinical Lectures Druitt's Modern Surgery Dujardin-Beaumetz's Dict'y of Therapeutics Duncan on Diseases of \Vomen r*Dunglison's Medical Dictionary . Edis on Diseases of Women . Ellis' Demonstrations of Anatomy Emmet's Gynaecology Erichsen's System ot Surgery Esmarch's Early Aid in Injuries and Accid'ts Farquharson's Therapeutics and Mat. Med. Fenwick's Medical Diagnosis Finlayson's Clinical Diagnosis Flint on Auscultation and Percussion Flint on Phthisis .... Flint on Physical Exploration of the Lungs Flint on Respiratory Organs Flint on the Heart Flint's Clinical Medicine Flint's Essays .... ^Flint's Practice of Medicine Foster's Physiology . . . . Fothergill s Handbook of Treatment . "^ownes" Elementary Chemistry . _ 'ox on Diseases of the Skin . Fuller on the Lungs and Air Passages . Galloway's Analysis .... Gibuey's Orthopaedic Surgery Gibson's Surgery . . . . Gluge's Pathological Histology, by Leidy Gray's Anatomy ..... Greene's Medical Chemistry . Green's Pathology and Morbid Anatomy Griffith's Universal Formulary Gross on Foreign Bodies in Air-Passages Gross on Impotence and Sterility . Gross on Urinary Organs .Gross' System of Surgery . Gusserow on Uterine Tumors Gynecological Transactions . . Habershon on the Abdomen . . Hamilton on Fractures and Dislocations Hamilton on Nervous Diseases Hartshorne's Anatomy and Physiology . Hartshorne's Conspectus of the Med. Sciences Hartshorne's Essentials of Medicine Hermann's Experimental Pharmacology Hill on Syphilis Hillier's Handbook of Skin Diseases PAGE. FASK. 2 Hoblyn's Medical Dictionary 4 27 Hodge on Women ..... 28 6 Hodge's Obstetrics ..... 28 20 28 Hoftmanu and Power's Chemical Analysis Holden's Landmarks ..... 10 7 9 Holland's Medical Notes and Reflections 17 17 Holmes' System of Surgery 22 29 Horner's Anatomy and Histology 5 27 I Hudson on Fever . . . . . 18 29jpHyde on tlie Diseases of the Skin . 26 Jones (C. Handfield) on Nervous Disorders 18 24 Keating on Infants ..... 30 8 . 5,20 King's Manual of Obstetrics . Klein's Histology . . . . 29 5,13 5 La Roche on Pneumonia, Malaria, etc. . 18 19 La Roche on Yellow Fever .... 18 9 9 14 23 Laurence and Moon's Ophthalmic Surgery Lawson on the Eve, Orbit and Eyelid Lea's Studies in Church History Lea's Superstition and Force ... 23 23 31 31 18 Lee on Syphilis ...... 25 12 Lehmanh's Chemical Physiology . 8 12 *Leishman's Midwifery . 30 21 Ludlow's Manual of Examinations 5 . 25 Lvons on Fever ...... 18 24 Maisch's Organic Materia Medica . . . 11 8 Medical News ...... 1 8 Meigs on Childbed Fever .... 28 23 Miller's Practice of Surgery . 21 15 Miller's Principles of Surgery . . . 21 27 Mitchell's Nervous Diseases of Women . . 19 . 17 Morris on Skin Diseases .... 26 28 6 10 Neill and Smith's Compendium of Med. Sci. Nettleship on Diseases of the Eye . *Parrish's Practical Pharmacy . . . 5 23 11 5 19 Parry on Extra-Uterine Pregnancy Parvin's Midwifery ..... 29 29 10 13 1 M Pavy on Digestion and its Disorders . . Pepper's Surgical Pathology Pirne's System of Surgery . 17 5,13 21 > %r 'Play&ir on Nerve Prostration and Hysteria . ^*Playfair's Midwifery Politzer on the Ear and its Diseases . . 19 29 24 *> Power's Human Physiology .... Ralfe's Clinical Chemistry .... 5,8 5,10 8 Ramsbotham on Parturition 28 i 7 Remsen's Theoretical Chemistry . 9 16 *Reynolds' System of Medicine 15 21 Richardson's Preventive Medicine 17 11 Roberts on Urinarv Diseases 24 28 4 Roberts' Principles and Practice of Surgery Robertson's Physical Physiology . 20 5,8 27 Rodwell's Dictionary of Science 4 . 7 Sargent's Minor and Military Surgery . 21 28 Schsifer's Histology ..... 13 21 Seiler on the Throat, Nose and Naso-Pharynx 18 ; ji Skey's Operative Surgery . . . . Slade on Diphtheria .... * 21 18 16 16 Smith (Edward) on Consumption . Smith (11. II.) and Horner's Anatomical Atlas 18 5 18 *Smith ( J. Lewis) on Children . . . 30 18 *Stille & Maisch's National Dispensatory 12 18 *Stille''s Therapeutics and Materia Medica 12 18 Stimson on Fractures ..... 23 18 Stimson's Operative Surgery 20 16 Stokes on Fever ...... 18 16 Students' Series of Manuals . 5 14 Sturges' Clinical Medicine .... 16 8 16 Tanner on Signs and Diseases of Pregnancy Tanner's Manual of Clinical Medicine . 29 16 9 Tarnier and Chaiitreuil's Obstetrics 28 26 Tavlor on Poisons ..... 31 18 *Tavlor's Medical Jurisprudence . 31 10 20 Taylor's Pria. and Prac. of Med. Jurisprudence *Tnomas on Diseases of Women 31 27 21 13 Thompson on Stricture .... Thompson on Urinary Organs 24 24 31 '. 10 Todd on Acute Diseases .... 17 13 Treves' Applied Anatomy .... 5,6 11 Tuke on the Influence of Mind on the Body 19 18 Walshe on the Heart ..... 18 25 24 Watson's Practice of Physic . Watts' Physical and Inorganic Chemistry 15 10 20 *Wells on the Eye ..... 23 28 West on Diseases of Childhood 30 28 West on Diseases of Women 27 17 West on Nervous Disorders in Childhood 30 22 Williams on Consumption .... 18 19 Wilson's Handbook of Cutaneous Medicine 26 5 Wilson's Human Anatomy .... 5 5 Winckel on Pathol. and Treatment of Childbed 29 14 Wohler's Organic Chemistry 9 11 Woodburv's Practice of Medicine . 15 25 26 Woodhead's Practical Pathology . 13 Books marked * are also bound in half Russia. HENRY C. LEA'S SON & CO., Philadelphia. l III II III II Mill III | | | f | A 000 501 378 4 31970009825982 WM100 C6UTC 1&8H Clouston. ture s Clinical ie< diseases on mental WM100 C6i47c 1881* Clouston. Clinical lectures on mental diseases UCI CCM LIBRARY