LIBRARY 
 
 OF THE 
 
 UNIVERSITY OF CALIFORNIA. 
 
 ClMS 
 
A TEXT-BOOK OF INSANITY 
 
A TEXT-BOOK OF 
 
 INSANITY 
 
 BY 
 
 CHARLES MER.CIER 
 
 M.B., M.R.C.P.,"F.R.C.S. 
 
 LECTCBER ON INSANITY AT THE WESTMINSTER HOSPITAL MEDICAL SCHOOL 
 AND AT THE LONDON MEDICAL SCHOOL FOR WOMEN 
 
 Author oj "Sanity and Insanity," "Psychology, Normal and Morbid," 
 " lunacy law for Medical Men" etc. 
 
 LONDON 
 
 SWAN SONNENSCHEIN & CO., LIMITED 
 
 NEW YORK: THE MACMILLAN COMPANY 
 
 1902 
 
3RAICT 
 
 PRINTED BY 
 
 UA.ZELT, WATSON, AJfD VINIT, LD. 
 LONDON AND AYLESBURT 
 
Dedication* 
 
 TO 
 
 THOMAS CLIFFORD ALLBUTT, 
 
 M.A., M.D., LL.D., D.SC., F.R.S., 
 REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF CAMBRIDGE 
 
 IN RECOGNITION OF HIS EFFORTS 
 
 TO PROMOTE THE SCIENTIFIC STUDY OF INSANITY 
 DURING HIS TOO BRIEF TENURE OF THE OFFICE 
 
 OF 
 COMMISSIONER IN LUNACY. 
 
 3 !9( 
 
PREFACE. 
 
 YEAR by year the students to whom I lecture ask 
 me what book on insanity they ought to study, and 
 year by year I have to recommend books which I 
 know to be excellent in themselves, but which I feel 
 are of such bulk and volume as to be out of proportion 
 to the time which students can profitably give to 
 an outlying subject, and to the vast mass of other 
 material which they have to assimilate during their 
 brief curriculum. Before that important event which 
 took place in the year B.C. 2348,* medical students 
 might have spent forty or fifty years in preparing 
 for examination, and have looked forward to com- 
 mencing practice when they were entering their 
 second or third century, but nowadays it seems 
 incumbent upon their teachers to avoid discursive- 
 ness, and I think that our knowledge of insanity 
 has reached a point at which its various forms and 
 varieties, like those of bodily disease, can be described 
 as types, without having recourse to descriptions of 
 illustrative cases, which bulk so large in most text- 
 
 * According to Ussher, but the Septuagint has it B.C. 3246. 
 
 vii 
 
viii PREFACE. 
 
 books on the subject. Moreover, I was anxious to 
 pnt forward the distinction that I have drawn in 
 this book between forms of insanity and varieties 
 of insanity, a distinction which I think goes far to 
 solve the difficulties of classification which have been 
 so great a stumbling-block to successive writers on 
 insanity for^generations. 
 
 In giving a preliminary sketch of the normal 
 processes of which insanity is the disorder, I have 
 followed a course which is very unusual, but which 
 I have pursaed for many years in lecturing on the 
 pubject, and have found to be a very useful foundation 
 on which to build a knowledge of insanity. Special 
 stress is laid upon observation of conduct, which is 
 in my opinion the key to the subject. The causes 
 of insanity have also been separately dealt with, and 
 as I hold that there are not insanities, but insanity 
 only, this course is at once convenient and logical. 
 
 C. M. 
 FLOWER HOUSE, CATFOKD. 
 
CONTENTS 
 
 PAGE 
 
 INTRODUCTION xi 
 
 PART I. THE INSTITUTES OF INSANITY. 
 
 CHAPTER I. Conduct 1 
 
 II. Mind 20 
 
 III. Certifiability and Fitness to be at Large . . 36 
 
 ., IV. The Causes of Insanity 40 
 
 PART II.-FORMS AND VARIETIES OF INSANITY. 
 
 CHAPTER V. Forms and Varieties of Insanity ... 67 
 
 VI. Forms of Insanity 69 
 
 A. Weakmindedness . . 69 
 
 B. Stupor . . 72 
 
 c. Depression 72 
 
 D. Excitement 81 
 
 E. Exaltation 85 
 
 F. Suspicion 90 
 
 G. Systematised Delusion .... 92 
 H. Obsession and Impulsiveness ... 92 
 K. Moral Perversion 96 
 
 VII. Varieties of Insanity 100 
 
 1 Idiocy and Imbecility 100 
 
 2. Dementia 107 
 
 3. Stupor 117 
 
 4. Acute Delirious Mania . . . .124 
 
 5 Acute Insanity 127 
 
 6. Fixed Delusion ...... 140 
 
 ix 
 
i CONTENTS. 
 
 MUM 
 
 CHAPTER VII. Varieties of Insanity (continued). 
 
 7. Paranoia 142 
 
 8. Recurrent Insanity 151 
 
 9. Insanity of Reproduction .... 158 
 
 10. Insanity of Times of Life . . . .157 
 
 11. Insanity from Alcohol . . . .158 
 
 12. General Paralysis 164 
 
 13. Insanity of Epilepsy 187 
 
 14. Insanity of Bodily Disease . . . .194 
 
 PART III. LEGAL RELATIONS OF INSANITY. 
 
 CHAPTER VIII. Placing under Control 199 
 
 IX. Keeping under Control 210 
 
 X. Testamentary and Contracting Capacity . 213 
 XI. Criminal Responsibility 215 
 
 APPENDICES. 
 
 A. A Faulty Certificate, Showing the Mistakes usually Made . 218 
 
 B. Letters of Insane Persons 221 
 
INTRODUCTION. 
 
 WHEN the student of medicine passes to the study 
 of insanity, he crosses a scientific frontier, and enters 
 an entirely new province of knowledge. Hitherto his 
 purview has been limited to the processes that go on 
 within the body, and whatever references he had to 
 make beyond that field were indirect and of secondary 
 import. He needs to know the structure and functions 
 of the several organs of the body, and, when any 
 function is disordered, his calling is to take measures 
 to readjust the bodily processes to one another so 
 that they may work in harmony again. He has, in 
 short, to maintain the organism in a fit state to do 
 its work, whatever that may be, but with the doing 
 of the work he has no concern. What the work 
 may be, and with what efficiency it may be performed, 
 is no concern of his, except in so far as these things 
 may afi'ect the general capability of the organism 
 to continue its existence. His position towards the 
 patient is the position of the shipwright and the 
 engineer towards the vessel on which they are engaged. 
 Like them, he must be thoroughly acquainted with 
 the structure and function of every part, and, like 
 them, he must be upon the watch to repair the 
 structure and correct the function, when the one is 
 damaged or the other is at fault ; but with the 
 ship's course he has nothing to do. That is a matter 
 
xii INTRODUCTION. 
 
 altogether beyond his province. When the student 
 oversteps the bounds of medicine to enter upon the 
 study of insanity, he leaves the engine-room for the 
 quarter-deck. He is no longer directly concerned 
 with the integrity of the structure or the efficiency 
 of the engines. His function now is to set the ship's 
 course, to note the way in which she comports herself 
 in wind and weather, to study charts and tides, stars 
 and clouds, to watch the barometer and to sound the 
 lead, and generally to relinquish the observation of 
 the ship herself, and to take up that of her relations 
 to the world in which she moves. This is the function 
 of the student of insanity to study the individual, 
 not per se, or simpliciter, but in relation to the world 
 in which he exists, and in which he has to maintain 
 his existence. v/ 
 
 Insanity is often called disorder of mind, and this 
 it is, but it is much more than this. Were it disorder 
 of mind alone, we should not be called upon to treat 
 it; for we should know nothing about it unless we 
 happened to be subject to it ourselves. What goes 
 on in the minds of other people we can never know, 
 unless and until it is revealed to us by their conduct. 
 Only by disorder of conduct can we infer the existence 
 of disorder of mind, and when conduct is disordered, 
 we may safely and immediately infer, we are irre- 
 sistibly compelled to infer, the existence of insanity, 
 without stopping to investigate the condition of the 
 mind. If a general officer goes on parade in flannels 
 and practising the banjo ; if a parson goes into the 
 pulpit and plays cup and ball before the congregation; 
 if a hostess comes down to a dinner party in her 
 nightdress and curl-papers ; if a smith pulls a glowing 
 horse-shoe out of the fire with his naked hand ; if a 
 
INTRODUCTION. xiii 
 
 navvy tries to break up the road with a saucepan ; we 
 do not need to sit down and investigate the state of 
 their minds before we pronounce them insane ; the 
 state of the mind is left on one side and does not 
 enter into our consideration. We say at once that 
 such conduct is itself insane, and needs no further 
 evidence to establish the insanity. It is true that 
 there are cases, many cases, in which we do investigate 
 the state of mind, and in which we should not pro- 
 nounce an opinion on the sanity or insanity of the 
 patient until their mental condition had been in- 
 vestigated ; but these are cases in which a portion, 
 it may be a very large portion, of the conduct exhibits 
 no disorder ; in which the disorder of conduct is only 
 occasional, and affects only a small, though it may 
 be an important, department of conduct ; and in 
 which we have, perhaps, no opportunity of witnessing 
 any disorder of conduct. In such cases we investi- 
 gate the state of mind in order to discover whether 
 conduct is likely to exhibit disorder ; and it is an 
 index to the likelihood of disorder of conduct, not 
 as in itself exhibiting disorder, that disorder of mind 
 is important. If we discover a disorder of mind that 
 has no influence upon conduct, we cannot regard it 
 as an indication of insanity. 
 
 Mind and conduct are not the only things disordered 
 in insanity. The former is a sign, the latter is a 
 symptom, of disorder of the highest nerve processes, 
 whose function it is to actuate conduct, and whose 
 activity is the condition under which mental states 
 arise. These highest nerve processes have a double 
 function. Not only do they actuate conduct, and 
 thereby regulate the whole of the commerce between 
 the organism as a whole and the universe which 
 
xiv INTRODUCTION. 
 
 environs it, but they regulate also the whole of the 
 internal processes of the body with respect to one 
 another, harmonise and balance and preserve dne 
 relations amongst them. When the highest nerve 
 processes are disordered, therefore, there is disorder 
 among these bodily processes disorder which is often 
 inconspicuous, but which, in the deeper degrees of 
 insanity, is often very pronounced, and exhibits itself 
 in anomalies of skin, hair, nails, sweat, etc. super- 
 ficial and conspicuous examples of a disordered 
 metabolism which is doubtless present in the deeper 
 tissues also. 
 
 Conduct, however, is the main thing that is dis- 
 ordered in insanity. It is disorder of conduct that 
 gives to insanity its whole significance. Disorder of 
 mind without disorder of conduct, if it were possible, 
 would be unimportant ; if it were important, would 
 be unrecognisable ; and thus the first essential to a 
 knowledge of insanity is an enumeration of the main 
 features of conduct, and of the ways in which conduct 
 may be disordered. 
 
PART I. 
 
 THE INSTITUTES OF INSANITY 
 
or THE 
 UNIVERSITY 
 
 CHAPTER I. 
 
 CONDUCT. 
 
 CONDUCT is the pursuit of ends ; and an investigation 
 into the several activities that together constitute 
 conduct resolves itself into an analysis of the ends 
 which mankind pursue, and the apportionment to each 
 of its relative importance. 
 
 The outcome of the stupendous biological discoveries 
 of the latter half of the last century is to show that 
 all life is teleological, and that the great and ultimate 
 end to which all life is directed, towards which every 
 living being strives, for which every living being exists, 
 and to which all other ends are but means, is the 
 continuation of the race to which the individual 
 belongs. To each individual, life is not a gift but a 
 trust, to be employed in transmitting life to a new 
 generation ; and, this purpose effected, the raison 
 d'etre of the individual is at an end. This is very 
 clearly indicated in the lives of many of the lower 
 animals, in which reproduction is followed at once by 
 death. Hence the whole scheme of existence centres 
 around the reproductive function, and the first, the 
 greatest, the most important, the most fundamental 
 group of activities of which human, in common with 
 all other living, beings are capable, consists of those 
 
 1 
 
2 TEXT-BOOK OF INSANITY. 
 
 which directly subserve the reproductive function ; 
 activities which in mankind begin with the first 
 approaches of courtship, and do not cease until the 
 last child is established in the world, and capable, in 
 its turn, of handing on the sacred fire of life to a 
 succeeding generation. The reproductive activities fall 
 naturally into three groups those of courtship, of 
 reproduction proper, and of parentage. 
 
 The activities of courtship need not detain us, since 
 they are not very important, and are but little liable 
 to disorder. We witness in them, however, the same 
 curious phenomenon of reversal that we shall have to 
 notice in the manifestation of other instincts ; that is 
 to say, we witness conduct directed, not to the attain- 
 ment, but to the defeat, of the instinctive end. We 
 see women, instead of decking themselves in colours 
 and endeavouring to make themselves attractive by 
 becoming costume, assuming the trappings of a nun, 
 and adopting elaborate devices to make their appearance 
 repellent. 
 
 The reproductive function proper is subject to 
 several morbid aberrations. The commonest of these 
 is masturbation, to which a great deal of factitious 
 importance has been ascribed. There are few diseases 
 of the nervous system whose causation has not at one 
 time or another been attributed to masturbation, and, 
 in insanity, both the physician and the patient are 
 accustomed to regard it as a factor of the greatest 
 importance. It is probable, however, that its share in 
 the production of insanity has been much exaggerated. 
 As far as it is possible to judge, it seems most likely 
 that very few lads pass through the period of adoles- 
 cence without sporadic and occasional indulgence in 
 this vice ; and it is certain that in many cases it is 
 
CONDUCT. 3 
 
 practised with considerable regularity and frequency 
 without producing insanity. There is no doubt that 
 it is practised before the outbreak of the insanity by 
 a considerable proportion of those who become insane, 
 and by all who become insane before the age of twenty- 
 five ; and although it has unquestionably an influence, 
 varying with the person by whom, and with the extent 
 to which, it is practised, in precipitating the outbreak 
 and increasing its severity, yet it is to be regarded 
 upon the whole rather as a symptom than as a cause 
 of insanity in such cases. The excess with which it is 
 indulged in is due to that inherent lack of self-control 
 which is an inseparable part of insanity, and which is 
 so often conspicuous in its early stages. 
 
 Perversion of the sexual passion, or its direction 
 towards abnormal objects towards the same sex, for 
 instance and its gratification in abnormal ways with 
 accompaniments of brutality and blood-thirstiness are 
 subjects which have of recent years been treated by 
 certain writers with a lingering solicitude and a 
 minuteness of detail out of all proportion to their 
 importance. It is true that cases of such perversion 
 are not extremely rare, but they are not usually 
 attended by any other symptom of insanity, and the 
 question whether this perversion in itself constitutes 
 insanity is one which can scarcely be considered here 
 at length. It is certainly not so in law, and the 
 abnormal gratification of the sexual passion being a 
 criminal offence, the persons who are addicted to these 
 practices are convicted and sentenced as sane people at 
 every session of the Central Criminal Court, excuse or 
 mitigation of the offence, upon the ground of the 
 insanity of the act, being unknown. 
 
 Disorder of parental conduct is not infrequent. 
 
4 TEXT-BOOK OF INSANITY. 
 
 Among the lowest class of v the population in large 
 towns the obligations of paternity are frequently 
 neglected or altogether ignored ; and the occasional 
 desertions of infants and young children are instances 
 of defect in maternal conduct, defects which are some- 
 times paralleled by parents in higher social strata. 
 Excess of parental solicitude, to the extent that the 
 health of the parent is damaged, and even the life 
 sacrificed, by devotion to the offspring, is not very 
 uncommon, but is not a wide departure from the 
 normal, for parenthood of necessity implies self-sacrifice. 
 Nor can that diversion of the parental instinct which 
 leads an old maid to lavish attention upon a pug-dog, 
 a cat, or a canary-bird, in the absence of any more 
 appropriate object, be looked upon as abnormal. There 
 are, however, perversions of the parental instinct which 
 evince manifest disorder. Chief of these is the rage 
 of destruction, directed against the new-born offspring, 
 which is such a frequent and terrible feature in the 
 insanity of child-bed. It is remarkable that this re- 
 version of the parental instinct occurs in connection 
 with parturition among the lower animals also. Dogs, 
 pigs, and rabbits frequently kill and devour their new- 
 born offspring ; and ewes will often repel, and leave to 
 perish of starvation, the weaklier of their twin lambs. 
 The parallelism does not explain the occurrence, how- 
 ever, though no doubt it indicates the direction in 
 which an explanation is to be sought, and at present 
 this strange aberration of conduct remains inexplicable. 
 Next in importance to the reproductive activities 
 are the directly self-conservative those activities 
 whose performance is necessary to the maintenance 
 of life from hour to hour and from moment to 
 moment those by which obvious physical dangers 
 
CONDUCT 5 
 
 to life are averted. These are the activities by which 
 an individual avoids falling into pits ; collisions with 
 moving, and eke with stationary, objects ; falling into 
 fire or water ; drinking scalding fluids ; running 
 into dangers of ferocious or poisonous animals; and, 
 generally, those obvious dangers which prohibit us 
 from leaving young children without supervision. 
 Defect of the activities of this class is presented by 
 all young children, and in them the defect is normal ; 
 but when it is prolonged beyond the stage of child- 
 hood, the defect is morbid, and .is characteristic of 
 that class of the insane that is connoted by the term 
 " idiot." Defect of these activities is not always original. 
 It may be acquired. While idiots never attain to the 
 degree of intelligence that enables them to guard 
 themselves against these obvious dangers, there is 
 another large class of the insane who have acquired the 
 activities of this class in full, but who have subsequently 
 lost them, and these activities are among the last 
 to be lost in the deeper degrees of dementia. Deeply 
 demented persons, no more than young children, can 
 safely be trusted to be alone. They are apt to fall 
 downstairs ; to set their clothes on fire ; to lie naked 
 and shivering with cold, for want of sense enough to 
 pull the bedclothes over them ; to trip over steps, 
 or buckets, or what not, and fall; and to incur in 
 other ways dangers that arise from want of the simplest 
 care and forethought. 
 
 Among these primitive modes of activity, which are 
 acquired at a very early age and are lost only when 
 the later stages of dissolution are reached, is that 
 which mankind shares not only with the great majority 
 of mammals and birds, but with bees and ants and 
 other social insects, of depositing his excrement at a 
 
6 TEXT-BOOK OF INSANITY. 
 
 distance from his habitual haunts, and in such a 
 manner that it shall not soil his person and render 
 it offensive to his fellows. This mode of conduct is 
 very often defective in insanity, and very often affected 
 out of its turn, as it were, and at a much earlier 
 stage of dissolution than we should expect. It 
 is common to find insane persons in good physical 
 health, capable of acts of considerable elaborate- 
 ness, able not only to feed themselves, to undress 
 themselves, to converse with some intelligence, to 
 find their way from place to place in their cus- 
 tomary abodes, who yet, without any paralysis of 
 sphincters, pass their water and motions under them 
 as they sit and lie. Considering at what a very early 
 stage of development this faculty is attained, it is 
 remarkable that it should so often be lost long before 
 other faculties of much later attainment ; and its loss 
 is very significant and of very unfavourable import. 
 Whatever the form of the insanity, an insane person 
 who lapses from cleanliness in this respect very rarely 
 recovers. Usually the first appearance of this symptom 
 marks the beginning of the end. In acute cases it 
 very often means that the patient is going to die ; 
 in chronic cases it means that he is settling into 
 hopeless dementia. 
 
 This phase of conduct is susceptible not only of 
 defect, but of perversion. There are many insane 
 persons who not only soil their clothes with their 
 faeces, but who revel in paddling in their filth. They 
 wash their hands in it ; they knead it ; they take it 
 in their hands and plaster it about the walls and 
 furniture of their rooms, on their persons, on their 
 faces, and in their hair. Such reversal of the ordinary 
 normal conduct of mankind is difficult to account for, 
 
CONDUCT. 7 
 
 but though it is not in all cases explicable, there are 
 many in which an explanation can be conjectured. 
 There are some lunatics who are so lazy, whose 
 detestation of distasteful exertion is pushed to such 
 an extreme, that they will wet the bed from sheer 
 dislike of the trouble of getting out to make water. 
 Others there are who are possessed by an impish spirit 
 of malignity, and whose desire to give trouble and to 
 outrage the feelings of those around them will manifest 
 itself in this way ; and finally it is an extraordinary 
 fact, but one that cannot be doubted by those who 
 have had much experience of the insane that in some 
 cases pleasure of a sexual character is derived from 
 these practices, and they are undertaken with that 
 end in view. 
 
 The other directly self-conservative activities are 
 likewise frequently perverted, and even reversed. 
 Instead of conduct being directed to the preservation 
 of life and the quest of pleasure, it is directed by 
 a fury of self-destruction and an unquenchable desire 
 for the self-infliction of pain and suffering ; and one 
 of the commonest of the forms which is exhibited by 
 the perversion of the self-conservative activities is the 
 unwillingness, often amounting to obstinate refusal, 
 to take food. The refusal to eat may be due to a 
 conviction that all the food is poisoned, or it may 
 be deliberately adopted as a suicidal expedient; and 
 both of these motives are frequent. But more often 
 it is exhibited by patients who have not sufficient 
 intelligence to form either the hypothesis or the 
 intention, but in whom it is part of a brutish 
 resistiveness which leads them to oppose every mode 
 of activity that is proposed to them. They struggle 
 against being fed with the same mulish obstinacy that 
 
8 TEXT-BOOK OF INSANITY. 
 
 they struggle against being dressed, against being 
 undressed, against being sat down or stood up, against 
 walking about, against standing still, against every 
 form of activity that they are desired to undertake ; 
 and their struggles are varied by endeavours to injure 
 those who have care of them. The conduct that they 
 exhibit reminds us, on the one hand, of a wild animal 
 that resents its capture, and on the other of a jibbing 
 horse ; and its only plausible explanation is to regard 
 it as a resuscitation of such obsolete instincts as these. 
 
 The craving for suicide and self-injury exhibits 
 itself in many other ways besides that of refusing 
 food, and perhaps its commonest expression is in a 
 leap from a window. Persons without experience of 
 insane people usually consider that if a window is 
 shut and fastened so that it cannot be opened, the 
 precaution against a suicidal leap through it is com- 
 plete ; but a patient who is determined upon suicide 
 takes no account of the obstacle of a mere pane of 
 glass, and will jump through a shut window as readily 
 as through an open one. The craving for suicide 
 often exists without the pluck to carry the intention 
 into execution, and even among the insane, many 
 are saved from suicide by the lack of courage ; but, 
 on the other hand, in many cases the determination is 
 so fixed and obstinate that the most unlikely means 
 are employed for the purpose, the greatest ingenuity 
 and industry are exercised in finding an opportunity, 
 and nothing but unceasing vigilance will suffice to 
 prevent the act. A fragment of cup or tumbler, of 
 window-pane or chamber-pot, will furnish a cutting 
 instrument which will serve to open a vein or an 
 artery. A ligature will be found in a garter, an 
 apron -string, a shred of clothing or sheet, or of 
 
CONDUCT. 9 
 
 unravellings twisted together to form a string. A 
 couple of inches of water in a ditch or bath will 
 suffice for drowning; the back of a chair or the rail 
 of a bedstead is high enough for a gallows ; a hand- 
 kerchief squeezed into a ball may be stuffed into 
 the throat ; petroleum, or furniture polish, or any- 
 thing that seems nasty and unwholesome, may be 
 swallowed ; and thus the resources of the would-be 
 suicide are always at hand, and the only efficient 
 preventive is incessant and vigilant watchfulness. 
 
 Short of suicide, the melancholic, who is deeply 
 impressed with his own unworthiness, will endeavour 
 to diminish and obviate his comfort as far as he can. 
 If he will eat food at all, it must not be savoury or 
 daintily served ; his bed must be hard, his clothing 
 coarse, his occupation distasteful. He insists upon a 
 morbid and unreasoning asceticism. 
 
 The third class of activities of which conduct is 
 made up comprises those which Spencer has termed 
 indirectly self-conservative those by which the liveli- 
 hood is earned and the means are administered ; and 
 these also are often defective and sometimes perverted. 
 When defective, the defect, as in the previous class, 
 may be either original or acquired ; the activities 
 may never have been attained, or, once attained, 
 they may be lost. 
 
 Original defect of the indirectly self-conservative 
 activities is seen in two forms : the first, in which the 
 general level of intelligence is low, and the defect is but 
 a part and a manifestation of a general defect implicating 
 all forms of conduct ; the second, in which the defect 
 is either confined to this particular division of conduct 
 or is in it much more pronounced than in any other, 
 the remaining divisions being comparatively complete 
 
10 TEXT-BOOK OF INSANITY. 
 
 and the general level of intelligence up to the normal. 
 The first of these classes is constituted by the imbeciles, 
 by those who attain to the directly self-conservative 
 activities, but fail to progress further; or who attain 
 to some degree of conduct of this second class, but 
 who can never attain to the skill in any occupation 
 that is necessary to give their labour sufficient market 
 value for their support. They can do simple work, 
 but they cannot, unless carefully supervised, do even 
 the simplest work without making such blunders as 
 deprive the work of all value ; and when the cost 
 of the supervision is deducted from the value of the 
 labour, the balance is too small for them to live on. 
 If they are set to weed a garden, they will pull up 
 weeds and valuable plants indiscriminately ; if they 
 are set to beat a carpet, they will vigorously beat 
 it into a hole at one spot and leave the remainder 
 untouched ; tools they will either break or injure 
 themselves with ; letters they lose, or deliver to any 
 one but the addressee; and so forth. 
 
 Inability to earn a living may be due to a totally 
 different defect. To earn a livelihood requires moral 
 as well as intellectual qualities. It needs steady 
 industry. It requires such self-control, such self- 
 denial, such a degree of self-abnegation, as will allow 
 of the steady pursuit of an uninviting and perhaps 
 repellent employment, in spite of the solicitation of 
 others by which immediate pleasure may be gained. 
 It means, in short, the postponement of immediate 
 pleasure and the suffering of immediate pain, for the 
 sake of greater pleasure to be enjoyed in the future. 
 And this ability of self-control differs very widely 
 in different people, and is by no means a function 
 of the intellectual ability. Either may be highly 
 
CONDUCT 11 
 
 developed while the other remains distinctly below 
 the average ; and we frequently meet, on the one 
 hand, with stupid people whose sense of duty is 
 highly developed, and in whom self-control increases 
 into self-denial, and self-denial is pushed to asceticism ; 
 while, on the other hand, it is as frequent to meet 
 with clever people, persons of nimble intellect and 
 many accomplishments, who are so deficient in this 
 moral quality that they are incapable of continuing 
 any mode of occupation after it has ceased to be 
 pleasant and congenial to them. Such people are 
 deficient in the activities of the class now under 
 consideration. They are incapable of earning their 
 livelihood, and incapable by reason of a defect, which 
 we may term mental or moral as we choose, but 
 which is a defect, not in the direction of idiocy or 
 imbecility, but of a totally different kind. 
 
 The ability to administer the means, when gained, 
 is of equal and even of greater importance than the 
 ability to earn a livelihood ; for, while the first is 
 obligatory upon every one, there are many people who 
 are relieved by the exertions of their predecessors from 
 all need to earn their own livelihood. Defect in the 
 administration of the means may take either of the 
 forms exhibited by defect in the earning of the liveli- 
 hood. It may be due to general defect of intelligence, 
 so that the subject of it is unable to appreciate the 
 amount of his income, unable to grasp the relative 
 values of different commodities, unable to appreciate 
 the different purchasing power of different sums of 
 money ; so that he is at the mercy of any dishonest 
 person who chooses to ask him half a sovereign for an 
 ounce of tobacco or a box of matches, or to palm off 
 upon him a German lithograph as a genuine Eaphael, 
 
12 TEXT-BOOK OF INSANITY. 
 
 a broken-winded screw as a certain winner, ormolu 
 and glass as gold and diamonds ; so that he expends 
 his income and sinks into debt from sheer inability 
 to appreciate the relation between income and outgo. 
 Few persons are brought to ruin by this defect, how- 
 ever, for it is recognised in early life, and they are 
 usually made wards of court before they come of age, 
 so that the administration of their means is never in 
 their own control. 
 
 But the next defect is a very frequent one, and 
 brings scores of spendthrifts to ruin every year. It is 
 the moral defect of inability to postpone immediate 
 pleasure for the sake of a greater future benefit. The 
 spendthrift knows and appreciates the amount of his 
 income ; knows that the rate of his expenditure cannot 
 be maintained without inroad upon his capital ; knows 
 that he is living at a rate at which his capital will be 
 exhausted in a few years ; and yet the prospect of 
 certain ruin is insufficient to check his immediate 
 indulgence. 
 
 Allied to this defect is that which is known in 
 Scotch law as " facility " ; that which is characterised 
 by an inability to say " No " ; and this defect may be 
 original or acquired. Often it is congenital. There 
 are very many persons of weak character who are 
 unable to withstand solicitation, who give to every 
 beggar and lend to every " sponge " money which they 
 know they cannot well afford, from lack of the moral 
 courage, force of character, or strength of will to 
 refuse. These are the people who are ruined by en- 
 dorsing bills and becoming security for their friends. 
 Again, there are people who, while in the vigour of 
 health, are able to repudiate such proposals, but who 
 weakly accept them when enfeebled by illness or in the 
 
CONDUCT. 13 
 
 decay of old age. These are the people whose wills are 
 disputed upon the ground of undue influence, who 
 make wills or deeds of gift in favour of their nurses or 
 landladies, to the exclusion of their own near relatives. 
 
 The administration of the means may be perverted. 
 The instinct of accumulation may be present in such 
 excess that expenditure is grossly inadequate. A man 
 who is well able to afford a house and a decent estab- 
 lishment will live in a single room, cook his own food, 
 go without such decencies of life as table-linen, carpets, 
 clean crockery, or change of clothes, deny himself the 
 use of artificial light, restrict to a dangerous extent 
 his fire, live a stranger to soap, comb, blacking, and 
 clothes-brush. When economy is pushed to such a 
 degree of miserliness as in the cases of Daniel Dancer 
 and John Elwes, the perversion of conduct in itself 
 constitutes insanity. 
 
 The next class of activities are those by which the 
 individual maintains his relations with the community 
 to which he belongs, and these, like other activities, 
 are susceptible of defect and perversion. 
 
 Communities exist by virtue of the self-restraint of 
 the component individuals, by which self-regarding 
 activity is limited so that the activities of the other 
 members of the community shall have free play within 
 similar limits ; and in order that the community may 
 hold together and continue, each individual must do 
 things for the common welfare which, if he lived in 
 solitude, he might without detriment leave undone. 
 When he lives in a community, he must so restrain 
 and regulate his activity as not to impair, nor even 
 to jeopardise, the safety, the property, and the self- 
 respect of his neighbours; and more than this, he 
 must take his share of the common burdens. He must 
 
14 TEXT-BOOK OF INSANITY. 
 
 contribute to its security and defence both from in- 
 ternal and external dangers ; he must contribute to its 
 solidarity and cohesion, not only by abstinence from 
 disintegratory conduct, but by an active execution of 
 such deeds as draw closer the bonds of fellowship and 
 knit more securely the strands of society. He must 
 abstain from violence, dishonesty, and slander; and, 
 above and beyond this abstinence, he must exercise 
 self-restraint in those hundred little ways by which the 
 conduct of a person in the presence of others is shorn 
 of indulgences which he allows himself when alone. 
 He must pay taxes, serve on juries, and contribute 
 by similar exercises to the common welfare ; and, in 
 addition to this, he must perform those acts of cere- 
 monial and small benevolence which, under the name 
 of politeness and courtesy, dimmish repulsion and 
 increase cohesion among the units of which the society 
 consists. Thus each form of conduct, whether in- 
 hibitory or active, is divisible into a major and a 
 minor section ; and while the opportunities and 
 occasions for the exercise of the activities of the 
 major section are comparatively infrequent and few, 
 the opportunities and occasions for the exercise of 
 the minor activities are frequent and, so long as the 
 individual is in the presence of his fellows, continuous. 
 Each major section may be dealt with separately, while 
 the minor may be considered together. 
 
 The exercise of self-restraint, when it is directed to 
 the forgoing of whatever advantage may be gained by 
 injuring others in person, or property, or feeling, is 
 termed "morality"; and the doing of such injurious acts 
 is " immorality," and may or may not be crime, accord- 
 ing as it is or is not punishable by law. Immorality and 
 crime, while they are disorders of conduct in the sense 
 
CONDUCT. 15 
 
 that they are departures from what the universal 
 consent of mankind admits that conduct ought to be, 
 are not necessarily disorders in the sense that they 
 partake of the nature of insanity. They may be sane 
 or insane according to circumstances, and the reader 
 who is interested in the circumstances which dis- 
 tinguish the sane from the insane variety of im- 
 morality and crime should consult the article on " Vice, 
 Crime, and Insanity" in Clifford Allbutt's "System 
 of Medicine." 
 
 The ability to serve the community in active ways, 
 whether by partaking in its defence against internal or 
 external foes, or by undertaking municipal or political 
 duties, is precisely the same kind of ability as is 
 required for the furtherance of the welfare of the 
 individual himself, and the same act which is under- 
 taken for the one end often serves the other ; so that 
 no separate treatment of the defects and disorders of 
 this division of conduct is needed. 
 
 It is in the minor activities of social life, in matters 
 of politeness, of convention, of ceremony, of courtesy, 
 that defect and disorder of conduct first exhibit them- 
 selves in those cases in which insanity comes on slowly, 
 or in which it does not advance far. As these are 
 the latest activities to be acquired, so they are the 
 earliest to decay in those cases in which an order of 
 decay can be discerned. When the defect of conduct 
 is merely quantitative when, that is to say, there is 
 a general diminution of the amount of energy available 
 for expenditure in conduct, as in the gradual advance 
 of age then defect is first and most perceptible in 
 those forms of conduct that demand for their actua- 
 tion the largest amounts of energy, and activities are 
 abandoned in the order of the vigour which they need 
 
16 TEXT-BOOK OF INSANITY. 
 
 and of the fatigue which they entail. Athletic exercises, 
 jumping, running, climbing, rowing, and so forth, are 
 the first to go ; and the acts of politeness and courtesy 
 which make so small a demand upon vigour and energy 
 are retained to the last. But when, as in insanity, 
 conduct suffers what may be termed a qualitative 
 defect when activities are lost without respect to the 
 amount of energy needed for their execution, but in the 
 inverse order of their acquirement then these little 
 offices are the first to show defect. In a large pro- 
 portion of cases of insanity defect of these qualities 
 is unnoticed, for the insanity comes on so rapidly that 
 the more fundamental and important activities of self- 
 conservation are reached at the outset, or very early in 
 the course of the malady ; and the disorder or defect 
 of these is such an important and such a conspicuous 
 factor in the case that the loss of the others passes 
 unnoticed. When a house is shaken by an earthquake, 
 we are too apprehensive of the collapse of the roof and 
 walls to notice the breakage of the crockery. Thus it 
 happens that, in a large proportion of cases of insanity, 
 defect and disorder of these qualities do not need 
 to be considered. But there is a numerous and very 
 important class of cases cases that are the most 
 difficult of all to deal with in practice in which 
 these minor activities alone exhibit disorder, and 
 then it is often difficult to recognise that insanity 
 exists; difficult, when one has satisfied oneself, to 
 convey the conviction to others ; and often impos- 
 sible to establish a sufficient degree of insanity to 
 set the law in motion and sequestrate the individual 
 from the management of himself and his affairs. 
 
 When the minor social activities are disordered, 
 then the minor activities among the self-conservative 
 
CONDUCT. 17 
 
 and reproductive activities are usually disordered along 
 with them ; and disorder of the whole group of minor 
 phases of conduct may now be considered together. 
 
 The beginnings of insanity, when insanity begins 
 slowly, are often very slight. The irritable man shows 
 such an increase of irritability as makes his family 
 stare ; the talkative man monopolises conversation more 
 completely than usual ; the uxorious man becomes even 
 more demonstrative ; the egotist brags more auda- 
 ciously ; the querulous complains more bitterly ; the 
 moody man has longer and more frequent periods 
 of deeper gloom ; any little peculiarity of conduct 
 which is native and not assumed becomes exaggerated. 
 In this stage insanity is not recognised; indeed, in 
 this stage insanity does not exist. It needs a wider 
 departure from the normal to justify us in diagnosing 
 insanity, but yet this is the beginning of the malady ; 
 the difference between this state and recognisable 
 certifiable insanity is a quantitative difference, a 
 difference of degree only, and a further advance of 
 the malady is marked at first by an exaggeration of 
 the same defects. 
 
 But if the most conspicuous features in the man's 
 normal conduct were artificial and assumed, if they 
 were the expression, not of deeper and more funda- 
 mental peculiarities of nerve structure, but of characters 
 of late acquirement, and therefore of little fixity and 
 endurance, then the mark of the onset of insanity 
 is a " change in the nature" of the man, and the 
 change is always in the direction of degradation. 
 The kindly and forbearing man becomes irritable 
 and quarrelsome ; the reticent man becomes expan- 
 sive, and expatiates to strangers and servants upon the 
 misdeeds of members of his family; the refined and 
 
 2 
 
18 TEXT-BOOK OF INSANITY. 
 
 gentlemanly man consorts with artisans and labourers 
 and frequents low public-houses; the man of cleanly 
 life visits brothels, and chums with loose women ; the 
 cautious, prudent man of business launches out in 
 wild speculations; the modest, retiring man thrusts 
 himself forward into all kinds of society, writes long 
 and familiar letters to persons with whom he has only 
 a bowing acquaintance, asking favours, offering benefits, 
 and making appointments ; the parsimonious man 
 becomes lavish, and the generous man parsimonious. 
 In this early stage of the malady no intellectual 
 defect may be apparent, or if there be any intellec- 
 tual defect, it is displayed only in the inability to 
 recognise and realise the impropriety of the conduct. 
 If you remonstrate or reason with him, you will be 
 astonished at the astuteness with which he justifies 
 an.l accounts for his conduct. You adduce instances 
 of his irritability and quarrelsomeness, and he admits 
 that he lost his temper, but, then, consider the pro- 
 vocation ! and he gives you an account of the incident, 
 not wilfully garbled, but highly coloured, and such 
 as, if you admit that it appeared so to him, you must 
 admit that his retaliation was not excessive. Does 
 he consort with labourers in low public-houses ? He 
 was unable to sleep, and at four o'clock on a summer 
 morning he dressed and went abroad. He has always 
 been interested in the lives of the labouring class, has 
 held night-schools for them, and started slate clubs, 
 and so forth. On this morning he met some of his 
 former pupils going to their work, and naturally began 
 to talk to them ; the conversation became so interesting 
 that he accompanied them to the house where they 
 took their breakfast, and then could do no less than 
 stand them beer all round. Tell him that he is 
 
CONDUCT. 19 
 
 squandering his means, and he will almost convince 
 you in spite of yourself that his expenditure was 
 justified ; that, in the first place, he could afford a 
 flutter; and, in the second, the chances of success 
 in his venture were so great as to justify the 
 speculation. 
 
 Disorder of other divisions of conduct is scarcely of 
 sufficient importance to need separate consideration. 
 Defect of religious conduct is common enough without 
 carrying with it any implication of insanity ; but 
 excess and disorder are occasionally seen, and are 
 more decidedly abnormal. When a girl passes whole 
 days and nights upon her knees in prayer, and cannot 
 be prevailed upon to rise, even to eat and drink, or 
 to take her fair share in the duties of the household ; 
 when a youth enters his father's office, harangues the 
 assembled customers upon their sins, prays aloud for 
 them, and finally dismisses them with his blessing ; 
 the morbid degree of the excess is no longer in doubt ; 
 but such disorder of the religious portion of conduct is 
 rarely the most important, is rarely even the most 
 conspicuous disorder. It is not so much the time 
 spent in prayer as the neglect of all other and more 
 urgent duties that is the important disorder in the 
 first case; it is not so much in the second case the 
 prayer, as the inability to appreciate the inappropriate- 
 ness of his conduct, that is the important element in 
 the conduct of the youth. 
 
CHAPTEE II. 
 
 MIND. 
 
 ALTHOUGH, as has been said, insanity is not exclusively, 
 nor even primarily, a disorder of mind, yet mind is 
 always disordered in insanity, and no account of the 
 preliminaries or institutes of insanity would be com- 
 plete in which the constitution and the disorders of 
 mind were ignored. 
 
 It has already been pointed out that life is essentially 
 and necessarily teleological, the prime purpose of every 
 living thing being to continue the existence of the 
 stirp to which it belongs ; and corresponding with 
 this central fact in conduct is the central factor in 
 mind, which we denominate desire. Desire of re- 
 production, the sexual attraction, the craving for 
 maternity these are the foundations of the human 
 mind, and to them all other mental states and pro- 
 cesses are subservient and contributory. Reproduction 
 cannot be effected until maturity is attained, nor can 
 the offspring be nourished and provided for unless 
 the life of the parent is preserved unimpaired ; and 
 hence, growing out of the primordial desire of re- 
 production, is the desire of self-preservation ; and 
 from this stock, again, arise many subordinate desires. 
 The competition of the human race with its environ- 
 ment, both organic and inorganic, and the competition 
 
 20 
 
MIND. 21 
 
 of individuals of the human race inter se, has eventuated 
 in the aggregation of individuals into communities ; 
 and the exigencies of social life have given rise to 
 a large group of important desires, whose action is 
 to conserve and consolidate communities ; and these 
 constitute another stock, out of which many subordinate 
 desires arise. 
 
 Living, as he does, in a world of moving objects, 
 and being himself endowed with motion, man is 
 constantly receiving motion from without and emitting 
 motion from within. To each of these factors in 
 experience a mode of consciousness corresponds. With 
 the reception of motion occurs sensation ; with the 
 emission of motion occurs volition. Motion is neither 
 received nor emitted at random. By the organs of 
 sense certain modes of motion are filtered out from 
 the rest, are, where necessary, magnified and intensified, 
 and are discriminated into innumerable shades ; and 
 those sensations occupy the largest share of conscious- 
 ness whose corresponding modes of motion are the 
 most important to us, as giving us intelligence of 
 those occurrences in the outside world which most 
 affect our welfare. And when motion is emitted, it 
 is emitted, not at random, but in such combinations 
 of movement as are best adapted to secure benefit 
 from the circumstances that are made known to us 
 by sensation. So that between reception and emis- 
 sion there is of necessity an internal rearrangement 
 or redistribution of the streams of motion, such that 
 the emitted motion is adapted to the circumstances 
 disclosed by the received motion. This redistri- 
 bution of motion is the physical substratum of 
 thinking. The altered disposition of tissue that 
 results from the redistribution of motion endures, 
 
22 TEXT-BOOK OF INSANITY. 
 
 and this endurance of structural alteration is the 
 physical basis of memory. 
 
 These, then, in brief, are the faculties or divisions 
 of mind whose disorders we have to examine desire, 
 sensation, thought, volition, and memory. Of these, 
 desire need not detain us, since it is so closely 
 determinant of conduct that a consideration of its 
 aberrations would be a repetition of the previous 
 section. Neither need we consider the disorders of 
 sensation, since these, by common consent, are matters 
 not so much for the psychologist as for the physiologist. 
 There remain the disorders of thought, volition, and 
 memory. 
 
 The most rudimentary form of thought is the 
 process of perception, by which a cluster of remem- 
 bered sensations is added to, and grouped around, a 
 presented sensation, in such wise that the whole 
 forms the percept of an object present to sense. To 
 the visual sensation of a patch of greenish-yellow 
 colour of varying shade are added the remembered 
 qualities, previously experienced in connection with 
 similar appearances, of size, shape, solidity, weight, 
 fragrance, smoothness, and so forth, together with the 
 remembrance of the sound " apple " ; and the whole 
 of these memories, when combined with the presented 
 sensation of the patch of colour, make up the percept 
 of the apple. The process thus characterised is liable 
 to three modes of error. 
 
 (1) In the first place, the presented sensation may 
 fail to suggest the remembered sensations, or some 
 of them, and the object may not be perceived for 
 what it is. The appearance of steam rising from 
 the surface of water has always in experience been 
 associated with a high temperature of the water, and 
 
MIND. 23 
 
 this appearance, when presented, ought to arouse the 
 remembrance that the water is hot. But in cases, 
 for instance, of deep dementia, the presented sensa- 
 tion fails to arouse the associated memory ; the 
 patient fails to perceive that steaming water is hot, 
 and scalds himself in consequence. Such a defect of 
 the process of perception may be termed imperception. 
 
 (2) In the second place, the presented sensation may 
 arouse a cluster of memories, but the qualities thus 
 remembered, and combined with the sensation into 
 a percept, do not, in fact, inhere in the object per- 
 ceived. I see a piece of cord lying on the floor, and 
 to the sensation which this object presents to my 
 sense I add the qualities of spontaneous movement 
 and of life, and the aggregate of these memories 
 make up the percept, not of a piece of cord, but 
 of a snake, and I perceive a snake wriggling on the 
 ground, where in fact there is nothing but a length 
 of cord. Or the wind blowing through the telegraph 
 wires produces aerial vibration, which impinge upon 
 my ear and arouse in me a sensation of sound ; to 
 this sensation I add memories of articulated words 
 and of their meaning, and I perceive that voices are 
 calling to me and abusing me with foul names. Such 
 cases of erroneous perception, or ill perception, are 
 termed illusion. 
 
 (3) In the previous case, although the wrong cluster 
 of memories was added to the sensation, yet there 
 really was an impression made on the organ of sense 
 to arouse the sensation and elicit the memories. 
 There was no snake on the ground, but there was a 
 cord ; there were no voices calling, but there were 
 sound-waves impinging on the ear. But if I saw a 
 snake upon the ground without the excuse of the 
 
24 TEXT-BOOK OF INSANITY. 
 
 cord, if there were nothing at all lying there, or 
 if I heard voices calling when the air was still, and 
 there were no sound-waves impinging on my ear, 
 then the error of perception would be a wider 
 departure from the normal, and then it would be 
 termed, not illusion, but hallucination. It is some- 
 what doubtful whether, in fact, there is such a thing 
 as a pure hallucination, without any provocation what- 
 ever from impressions of sense. There may, it is 
 true, be no agent giving rise to sense impressions 
 from without the body; but the sensation, which I 
 interpret as 'a snake, may be due to a rouleau of 
 blood corpuscles in my vitreous, and the sensation 
 which I interpret as a voice may arise from the 
 friction of blood in my carotid arteries. 
 
 On a higher level than perception, the thinking 
 process is often disordered in ways that are some- 
 what similar, and the erroneous modes of reasoning 
 are fallacies, which need not be examined here. 
 The errors which are important to the alienist are, 
 in the process of thinking, confusion, and in the 
 thoughts that result from the reasoning process, those 
 incorrigibly erroneous beliefs that are termed delusions. 
 
 Confusion of thought is extremely common, both 
 in the sane and in the insane, and is an inseparable 
 accompaniment of delusion ; but it is often present 
 also where there is no such definite belief as the 
 term delusion can be applied to. When a person 
 believes that he possesses incalculable wealth, and 
 at the same time begs importunately for sixpence 
 wherewith to buy himself tobacco, the retention of the 
 belief in his wealth, in face of the knowledge of his 
 poverty which his importunity evinces, indicates an ex- 
 traordinary confusion of thought. It shows an inability 
 
MIND. 25 
 
 to bring his thoughts together and make comparisons 
 between them; or, supposing that the discrepancy 
 is brought to his notice, and makes, as it assuredly 
 will make, no difference in his belief, it indicates an 
 inability to appreciate difference, a confusion of mind, 
 which, to a normally minded person, is wholly incom- 
 prehensible. Confusion of thought is thus inseparable 
 from delusion, but by confusion of thought is usually 
 meant something different from this disability to 
 correct a deluded belief. There are states of mind 
 in which there appears to be a flow of disconnected 
 and incongruous ideas, and in which the flow of 
 language, at any rate, is disconnected and incon- 
 gruous, or, as it is usually called, incoherent ; and 
 this is the usual condition in acute insanity. In 
 such cases the patient is not himself aware of any- 
 thing unusual or abnormal in his mental condition. 
 There are other cases in which the mind is confused, 
 and in which he feels and knows it is confused, and 
 ' deplores the confusion. Whether recognised or not 
 by the subject of it, confusion of thought is the rule 
 in insanity ; and even in those insane persons who 
 are intellectually acute and even brilliant, there will 
 be found a region of thought in which it is impossible 
 to bring home to them the incorrectness, absurdity, 
 and preposterousness of their thoughts, and this 
 inability will be found to rest upon confusion. 
 
 The chief intellectual disorder that occurs in in- 
 sanity is, however, delusion by which is meant a 
 belief that is not only erroneous, but incorrigibly 
 erroneous ; which is not only incorrect, but which 
 cannot be corrected even when the means of correction 
 are furnished. A woman believes that her child is 
 dead, and when the live child is produced and shown 
 
26 TEXT-BOOK OF INSANITY. 
 
 to her, she still maintains her belief that it is dead. 
 The belief is not only erroneous, is not only without 
 foundation, but even when contradicted by the plain 
 evidence of her senses, it is incorrigible. A man 
 believes that he is a millionaire ; the facts that he is 
 an inmate of a workhouse or a pauper asylum, that he 
 is dressed in pauper garb, lives among paupers, is 
 subject to the directions of rough, uneducated nurses, 
 that he never has a penny wherewith to get a shave, 
 or a bit of tobacco, or a drink, that he lives on coarse 
 fare, in most undesirable surroundings, have no in- 
 fluence whatever in dissolving his belief. In spite of 
 the plainest evidence to the contrary, the belief is 
 incorrigible. Such a belief is a delusion. 
 
 Delusion is usually accompanied by a feeling of 
 misery or a feeling of happiness, the feeling in either 
 case being out of proportion to, and unjustified by, the 
 circumstances of the individual ; and the feeling and 
 the delusion together make up a state of mind which 
 may be called the " delusional state." Occasionally the 
 unjustifiable feeling of happiness or misery exists in 
 the absence of any erroneous belief or delusion properly 
 so-called, and in that case we may apply the term 
 " delusional state" to this unjustified feeling alone, which 
 otherwise would have no general title, though the un- 
 justified feeling of misery without delusion is called 
 simple melancholia, and the unjustified feeling of happi- 
 ness may be called simple exaltation. Bearing in mind 
 that delusion does not usually exist alone, but is part of 
 a delusional state which includes unjustified exaltation 
 and depression, delusions may be classified as follows : 
 
 (1) Delusions with regard to the self, which may 
 refer either to the whole or to part only of the self or 
 personality. 
 
MIND. 27 
 
 (a) Delusions of the whole personality are of several 
 varieties, all rare. In one group the personality is in 
 some way altered, so that the patient speaks of himself 
 as " altered," " strange/' " unnatural," but is unable to 
 describe the alteration which he feels. In the second 
 group the altered personality co-exists with the original 
 personality, and the patient believes in a confused way 
 that there are two beings within his body, or that he 
 has another self somewhere outside of himself. In the 
 third group the personality actually is changed, and it 
 is only by straining the meaning of words that the 
 mental condition can be regarded as one of delusion. 
 In this condition a person, after a sleep, or an hysteric 
 attack, or some other crisis, wakes up a different person. 
 He has forgotten his past life, and has perhaps to be 
 re-educated ; he has changed his moral character, and 
 the honest or sober man has become a thief or a 
 drunkard, or vice versa ; he has changed his disposition 
 and proclivities, so that the steady, industrious workman 
 becomes a tramp and a vagabond. After a period of 
 very various duration, he has another crisis, from which 
 he wakes with his first self restored and the experiences 
 of his second life forgotten. 
 
 (6) Delusions with regard to part of the self. These 
 are the delusions that some one else, not another self, 
 but a stranger and an intruder, has gained a lodgment 
 in the body, and thinks the patient's thoughts, speaks 
 with his voice, and acts with his body. For the sayings 
 and doings of this interloper the patient regards him- 
 self as irresponsible, and, indeed, he often bitterly 
 resents the interference. Or, instead of another per- 
 sonality, he may have within him an animal or an 
 inanimate object a weasel in his stomach, a worm in 
 his head, a lobster in his bowels, or what not ; or his 
 
28 TEXT-BOOK OF INSANITY. 
 
 bowels are obliterated, he has no inside, his brains 
 have been taken out, his legs are of glass, and so on. 
 Persons with delusions of part of the self have often 
 some actual bodily disease of that part which localises 
 the delusion. 
 
 (2) The second great class of delusions are those 
 which refer, not to the self alone, but to the relation 
 between the self and its surrounding circumstances. 
 This class falls naturally into two groups delusions of 
 increased welfare and delusions of diminished welfare ; 
 and each of these may be further divided into delusions 
 of the relation of the self to its surroundings and 
 delusions with regard to the relation of the surroundings 
 to the self. 
 
 (a) In the first group delusions of increased wel- 
 fare the second distinction that has been made 
 is not of clinical importance, since delusions of in- 
 creased welfare in the relation of surroundings to self 
 commonly accompany delusions of increased welfare in 
 the relation of self to surroundings. They may there- 
 fore be considered together. The delusions are on the 
 one hand delusions of exaggerated worthiness and 
 exaggerated competence and power on the part of the 
 deluded person, and on the other are deluded exaggera- 
 tions of the esteem in which he is held. Individuals 
 so affected believe that they are wealthy, able, learned, 
 skilful, powerful, and generally worthy and competent, 
 in various degrees of exaggeration. They possess more 
 millions than they can express, and invent new words 
 to signify their wealth ; they are more brilliant authors, 
 have written more and abler books, scaled more and 
 more difficult mountains, made more runs at cricket, 
 owned faster yachts, begotten more children, married 
 more wives, and so forth, than any other human being 
 
MIND. 29 
 
 ever dreamed of. They have been created dukes, 
 kings, emperors, gods. They are God. They are to 
 receive, or they have received, favours the most 
 striking from persons in the most various and the 
 most exalted positions. No position is too great for 
 them to attain, no fortune too great to be conferred 
 upon them. The grandiosity of the delusion is very 
 various in degree, and does not always reach the 
 extreme exaggeration that has been described, but 
 the general features of this delusion are common to 
 the class. 
 
 (6) The second group of delusions of this class 
 consists of those of diminished welfare, and is divisible 
 into two sub-groups that are clinically distinct : 
 
 (i) The first of these consists of delusions of dimin- 
 ished welfare in the relations of self to surroundings, 
 and is co-extensive with the delusions of melancholia. 
 They are delusions of un worthiness and incompetence, 
 the self-accusatory delusions, delusions of sin and 
 crime and vice on the one hand, and of impotence 
 and inability and incapacity on the other. Persons 
 affected with delusions of this class abandon themselves 
 to despair as sinners of the unpardonable sin, or give 
 themselves up to the police for crimes that they have 
 not committed, or confess to faults and vices of which 
 they are wholly innocent, or which they greatly exag- 
 gerate. They have brought themselves to ruin, they 
 have brought poverty and disgrace upon their families, 
 they have in some unexplainable way involved the 
 whole village, the whole country, the whole human 
 race, in ruin and disaster. There is no solace for them 
 in this world, and no hope in the next. Such is 
 the condition of those in whom melancholic delusions 
 are fully developed ; but minor degrees of the same 
 
30 TEXT-BOOK OF INSANITY. 
 
 delusions are very common. It is common to meet 
 with delusions of sin that are not yet unpardonable, 
 of ruin that is not yet complete, of inefficiency that 
 is not yet absolute. The delusions may exist in very 
 various degree, and in very varied combinations; but 
 in all we trace the double element of un worthiness and 
 inefficiency corresponding with the two categories of 
 passion and action. 
 
 (ii) Delusions of inimical relations of surroundings to 
 self form a very well characterised group of delusions, 
 distinct both in their character and in their clinical 
 occurrence from the last. They are different in cast 
 and occur in a different class of insane persons. They 
 are the delusions of persecution, of suspicion, of con- 
 spiracy. To this class belongs the whole group of 
 systematised delusions that is to say, delusions 
 under which the deluded person makes for himself 
 a new world, containing some malign principle to 
 whose operation the causation of events is referred 
 a world from which existences and events that do not 
 directly concern the deluded individual are gradually 
 excluded, until there remains at last only a self with 
 which alone the universe is concerned and a universe 
 dominated by some malign principle directed solely 
 against the swollen and bloated self upon which it 
 is centred. When this stage is reached, everything 
 that exists, everything that happens, exists only to 
 annoy the patient, happens only to injure him. As 
 he goes about the streets the people talk to each 
 other about him, or look at him in a significant way; 
 their attitudes, their gestures, their very dress even, 
 contain some occult quality which is intended to, and 
 does, annoy and injure him. The articles in the 
 newspapers refer to him. Books that pretend to be 
 
MIND. 31 
 
 books of travel or novels are really implicated in the 
 plot, and refer to him in some cryptic manner. He 
 is referred to in political speeches in the same way as 
 Bacon, according to Mr. Donelly, is referred to in the 
 plays of Shakespeare. Sometimes the centre and 
 origin of all this conspiracy is a single individual; 
 sometimes a group of individuals, also either real or 
 imaginary. It is the Lord Chief Justice, it is the 
 Commander-in-Chief, it is very often the head of 
 the asylum in which the patient is detained, or it 
 is a man or a body of men sent from the asylum in 
 which he was last detained, it is the lodger on the 
 floor above or below, it is the man who lives over 
 the way, it is some relative, or it is some wholly 
 imaginary being whom he knows to exist, but whom 
 he has never seen. But very often it is not an indi- 
 vidual, but an influence ; and if an individual or a group 
 of individuals, real or imaginary, his or their powers 
 are exercised through and by means of some occult 
 and mysterious influence. Most often just now it is 
 electricity ; in the first half of the last century it was 
 steam ; often it is chemical vapour, or a system of 
 mirrors or microscopical glasses ; or it is hypnotism 
 or mesmerism, or the Rontgen rays or wireless 
 telegraphy ; or it is something altogether too subtle 
 and mysterious to be expressed in any ordinary 
 language, and a new term has to be invented to 
 characterise it ; and in not a few cases it cannot be 
 expressed in intelligible language at all. The patient 
 then wanders into a meaningless jargon of words, 
 which may hang together in grammatical sentences 
 or may be a mere hash of incoherent words. 
 
 The region of thought, including that of belief, 
 is not the only region in which the mind may be 
 
32 TEXT-BOOK OF INSANITY 
 
 disordered. In cases which are much less frequent than 
 are cases of delusion, but which are not very infrequent, 
 the disorder is not primarily so much in the region of 
 belief as in that of will, and disorders of will are of two 
 kinds, which, although they appear very distinct, often 
 co-exist in the same case. 
 
 The first disorder of will is an exaggeration of what 
 is called weakness of character. There is an inability 
 to " make up the mind," to come to a decision, to 
 exercise a choice. The patient will hesitate for a long 
 time before he is able to decide whether to put on the 
 right boot or the left, which foot to begin with in 
 going upstairs, which pen to select out of the tray, 
 what word to use to express his meaning, whether to 
 walk this way or that, whether to take a stick or an 
 umbrella, and so on with all the decisions of life. 
 This is one form, and in strictness should be considered 
 the only form, of what is called folie du doute 
 hesitating insanity. 
 
 The second disorder of will is what is known as 
 obsession, in which the will of the patient is, as it 
 were, made captive and overpowered by an impulsion 
 to do some act which he loathes and abhors, but which 
 still obtrudes itself upon him, and at last gets itself 
 done in spite of his exertions to resist it. The mildest 
 form of obsession is familiar to most of us under the 
 title of words or phrases " running in the head." We 
 are most of us familiar with the occurrence of a verse of 
 poetry, a text of Scripture, a passage from some familiar 
 author, a proverb, or some other combination of words, 
 presenting itself to us and being repeated over and over 
 again in silence, until at last it commonly gets itself 
 uttered aloud. Most of us, too, are familiar with an 
 absurd impulsion, when we are walking along the 
 
MIND. 33 
 
 street, to step upon, or avoid stepping upon, the 
 dividing lines between the flagstones. Sometimes 
 this peculiarity is exaggerated. Usually it is a 
 temporary affair, and affects only such trifling 
 matters as have been instanced, but in some cases 
 it becomes enduring, or even permanent over long 
 periods, and is exhibited in much more important 
 departments of conduct. The words that present 
 themselves persistently, that refuse to be banished, 
 and that gain utterance at last, may be obscene and 
 objurgatory ; and their presence in the mind, and 
 still more their actual utterance, may be a source 
 of pain and grief to the person who utters them. 
 The act to which he is impelled by some internal 
 impulsion may be not the occasional and harmless 
 act of stepping on the divisions of the paving-stones, 
 or touching the posts as he passes along the street, 
 but a persistent, unremitting impulse to murder 
 his wife or children, an impulse which, if he is left 
 alone with them, and finds means at hand, may be 
 ungovernable. 
 
 Fortunately, the obsession is not often of this lethal 
 character. Very often, when folie du doute exists, 
 some degree of obsession is mixed with it ; and in 
 this case, not only is the period of hesitation unduly 
 prolonged, but it is filled up, not with the balancing 
 of alternatives as in the normal, but with some entirely 
 extraneous activity which has nothing to do with the 
 choice that is waiting to be made. For instance, the 
 patient who hesitates as to which boot to put on first 
 is occupied, during the period of hesitation, not with 
 balancing the respective desirabilities of putting on the 
 right boot and the left boot, but with counting; and 
 before every act on which he or she eventually decides, 
 
 3 
 
34 TEXT-BOOK OF INSANITY. 
 
 is interposed an interval which is occupied with count- 
 ing, say to ten, or some multiple of ten. 
 
 The next faculty or division or department of mind 
 that may be disordered is that of memory, and memory 
 may be disordered in several ways. Normally, when 
 we remember an event, we remember it with a certain 
 localisation in time that is to say, we remember it 
 not only as having happened, but as having happened 
 at a certain interval of time between now and then. 
 The localisation may not be precise ; we may be unable 
 to say whether it was a month or two months ago, 
 a year or eighteen months, ten years or fifteen; but 
 still we remember it with some localisation in time. 
 We refer it more or less definitely to a time so far 
 distant. Not only do we localise memories in time, 
 but we localise them in space also. That is to say, 
 we remember any particular event as one of a group 
 of experiences that occurred at the same time. When 
 I see this face, which I have seen once before, I not 
 only recognise it as one I have seen before, but, if 
 the memory is complete, I remember about how long 
 ago it was that I first saw it, and I remember also the 
 circumstances under which I saw it. I remember 
 whether I saw it at Mr. Jones's office, or at Mrs. 
 Smith's at-home, or at Eobinson's dinner-party. 
 
 In any of these respects memory may be defective. 
 I may fail to remember the face at all, to remember 
 that I have seen it before, to recognise it ; or, recog- 
 nising it as a face with which I am familiar, I may fail 
 to remember how long it is since I saw it ; or, remem- 
 bering vaguely that I have been introduced to its 
 owner recently within the last month or two I 
 may fail to remember the circumstances under which 
 I became acquainted with him. All these defects of 
 
MIND. 35 
 
 memory increase as age advances, and are most marked 
 in elderly people. Among the surrounding circum- 
 stances connected with experiences of things, the 
 names of the things are prominent, and the first 
 warning of the approach of senility is a growing 
 difficulty in remembering names; and beyond this, 
 a general impairment of nimbi eness in dealing with 
 substantives. Defect of memory is, of course, a matter 
 of degree. No one remembers all his experiences, 
 and to forget is as natural and as normal as to 
 remember, nor can any clear line be drawn between 
 a defect that is within the normal and one that is 
 beyond this bound. In practice, however, little difficulty 
 is experienced in deciding that a defect of memory is 
 morbid in degree, since by common consent no defect 
 is considered morbid that is not extreme. 
 
CHAPTER III. 
 
 CERTIFIABILITY AND FITNESS TO BE AT 
 LARGE. 
 
 A PATIENT may be insane without being certifiably 
 insane that is to say, although, by prolonged obser- 
 vation of his conduct, we may be convinced that his 
 mind is disordered, and that he is no longer fully 
 responsible for his acts, yet we may be unable to 
 describe in words any specific " fact indicating insanity 
 observed at the time of examination," and so to place 
 him under control. Such persons are extremely diiiicult 
 to deal with ; and though they often eventually become 
 certifiable, they contrive, before this stage is reached, 
 to run through large sums of money, often to ruin 
 themselves, and often to commit criminal acts. 
 
 But supposing a patient to be certifiably insane, the 
 first questions that have to be decided are whether he 
 may properly be allowed to remain uncertified, whether 
 he should be placed in private care, or whether he should 
 be sent to an institution. These are questions that 
 depend partly upon the nature and degree of the 
 malady, and partly upon the age, wealth, and other 
 circumstances of the patient. 
 
 The character of the malady is the most important 
 consideration. It may be stated categorically that 
 every case of acute insanity should be at once placed 
 
CERTIFIABILITY AND FITNESS TO BE AT LARGE. 37 
 
 in an institution, to whatever type the acute insanity 
 conforms, and to whatever variety of insanity it may 
 happen to belong. Every patient with acute insanity 
 is a potential suicide, and suicidal patients can only be 
 prevented from effecting their purpose by asylum treat- 
 ment. It is only in an institution specially constructed 
 for the purpose that the habit of incessant supervision 
 is maintained, and that the appliances for heating and 
 lighting and ventilation, the staircases, water-closets, 
 bedsteads, and other arrangements are specially con- 
 structed with a view to minimise the opportunities for 
 suicide. Moreover, patients who are acutely insane 
 need the presence of a medical attendant always 
 within call, for contingencies requiring instant 
 medical treatment are of frequent occurrence ; and 
 it is obvious that this condition can be secured in 
 an institution only. 
 
 For a somewhat similar reason, general paralytics 
 invariably require to be detained in an institution. 
 They are subject, throughout the whole of the first, 
 and often the second stage also, to sudden outbreaks 
 of violence, to deal with which the continued presence 
 of an adequate staff of attendants is necessary, and 
 this abundance of attendants is only obtainable in an 
 institution. 
 
 Lastly, all paranoiacs ought to be detained in insti- 
 tutions. All such patients are potential homicides, 
 and scarcely a month passes without the commission 
 of a murder by a patient of this description, who had 
 given abundant evidence beforehand that he ought to 
 be under efficient control. 
 
 Patients of these three classes ought always to be 
 treated in institutions, but they are not the only 
 patients for whom institution treatment is necessary. 
 
38 TEXT-BOOK OF INSANITY 
 
 All patients who need much control ought to be in 
 institutions, for only in them can much control be 
 exercised. Patients who are very noisy, or who are 
 very restless, or who are sexually excited, cannot be 
 properly managed in private care. 
 
 On the other hand, there are patients who ought not 
 to be sent to institutions if this course can be avoided. 
 Young girls or young lads should be kept out of insti- 
 tutions as long as possible, for the fact of their having 
 been placed under care may tell very seriously against 
 them in future life ; quiet dements can very well be 
 treated at home or in private care ; and persons whose 
 insanity is recent, is of a mild and subacute form, 
 ought usually to have a trial in appropriate surround- 
 ings outside an asylum, before recourse is had to this 
 extreme measure. 
 
 The means of the patient form a very important 
 factor in determining whether he shall be sent to 
 an asylum or no. In the case of a poor person, no 
 other alternative is possible, since, apart from the 
 expense of supervision, the mere abstention from work 
 reduces them to a condition of dependence ; while 
 wealthy men, who can afford plenty of attendants and 
 an isolated house with large grounds, can very well be 
 treated in their own homes. There are multitudes of 
 patients in pauper asylums who, if they possessed 
 adequate means, might be at large; and there are 
 multitudes of persons at large who, if they were not 
 fortunately in possession of means, would have to seek 
 the shelter of an asylum. It is a very common occur- 
 rence for a person to have sufficient intelligence to 
 administer his means capably if he happens to possess 
 any, and yet to have insufficient intelligence to earn 
 his livelihood. If he has means, he may very well live 
 
CERTIFI ABILITY AND FITNESS TO BE AT LARGE. 39 
 
 at large, but if he has none, he must be cared for in an 
 institution. 
 
 If it is determined that treatment in an institution 
 is unavoidable, or is desirable, the question will often 
 arise whether he should be placed there under a re- 
 ception order, or whether he should go of his own free 
 will as a voluntary boarder. There are but few cases in 
 which the latter alternative is really the best, though 
 it is often practicable, and sometimes the only practic- 
 able course. In such cases the patient must not only 
 be willing to place himself under care, but he must be 
 competent to form a judgment as to the expediency of 
 doing so, and he must be to such an extent of sound 
 mind that, even if it were desirable, it is not possible 
 to make a certificate of lunacy with regard to him. He 
 must be uncertifiable. 
 
 Neurologists, who are frequently consulted about 
 cases of insanity, though it is a subject of which they 
 have no special knowledge, almost invariably advise 
 that the patient should travel, and are particularly 
 fond of recommending a sea voyage. Travelling is, 
 however, almost always detrimental in the early stages 
 of insanity; and a sea voyage is probably the very 
 worst course that could be adopted. As will be seen 
 further on, all cases of acute insanity are potential 
 suicides, and on board ship the opportunity and 
 temptation to suicide are constantly present and con- 
 stantly obtruded, and effective supervision is almost 
 impossible. 
 
CHAPTER IV. 
 
 THE CAUSES OF INSANITY. 
 
 WHENEVER a mechanism fails to perform the duty 
 demanded of it, the reason must be either that the 
 work is too heavy for the mechanism or that the 
 mechanism is not strong enough for the work ; and 
 the two things are not exactly the same. When a 
 human organism breaks down under the stress of life, 
 in a way that the majority of men do not break down, 
 it is because either the individual is weaker than his 
 fellows, or the stress brought to bear on him is greater. 
 For every individual, as for every beam and every rope, 
 there is a breaking strain. Load a beam or a rope with 
 sufficient weight, and, whatever its strength, it will 
 break at last. Subject a man to sufficient stress, and 
 however well he may be constituted, he will become 
 insane. In estimating the factors that go to produce 
 insanity in any case, we have to consider, first, the 
 individual, and, second, the stresses to which he is 
 subject. 
 
 The fact that the majority of people are sane, indi- 
 cates that they possess a nervous organisation of 
 sufficient stability and strength to withstand the stresses 
 to which it is subject ; and if here and there one 
 becomes insane, it is because either his nervous 
 organisation was not strong enough to withstand 
 
 40 
 
THE CAUSES OF INSANITY. 41 
 
 ordinary stresses, or he has been subjected to stresses 
 of extraordinary severity. The great majority of 
 cases of ordinary insanity belong to the former 
 class ; cases of insanity of drunkenness, and of general 
 paralysis, belong to the latter. 
 
 We have no means of gauging the efficiency of a 
 person to withstand stresses, except by observation of 
 his behaviour under their incidence; but, since every 
 individual is the outcome and product of his ancestry, 
 we may make a rough guess at his efficiency by investi- 
 gating his heredity. That heredity has a very import-? 
 tant role in the production of insanity is proved, not 
 less by clinical experience than by the considerations 
 just dealt with ; but what it is that is inherited in cases 
 in which insanity " runs in the family " it is difficult to 
 say. Insanity is manifested in conduct, and it is 
 evidently absurd to speak of what a man is now doing 
 as an inheritance from his forefathers. The only thing 
 that can be clearly conceived as transmitted by inherit- 
 ance is structure ; and if a son " inherits insanity ? ' from 
 his father, what is transmitted from father to son must 
 be some structural peculiarity of nerve tissue. There 
 are several such peculiarities that may conceivably be 
 derived by inheritance. In the first place, the process 
 of development may be deficient in impetus; it may 
 come to a premature close ; and in that case the part of 
 the body which will remain undeveloped will be the 
 part which is the last to be completed that is to say^ 
 the highest regions of the brain. The degree of 
 development which is reached by these regions varies 
 much in different individuals, according to the strength 
 and persistence of the developmental impetus. When 
 these are exceptionally great, the highest nerve regions 
 become exceptionally well developed, and the individual 
 
42 TEXT-BOOK OF INSANITY. 
 
 attains to a high level of intellectual development. 
 When the process of development is feeble, and comes 
 to a premature close, the brain never attains full 
 development, and the individual never reaches the 
 normal intellectual standard. 
 
 But there are other forms of insanity than idiocy 
 and imbecility, and many of the insane whose insanity 
 " runs in the family " are of average, and even of more 
 than average, ability. How can we suppose that, in 
 such cases, the insanity is " transmitted " ? Or rather, 
 what is it that is transmitted by inheritance in such 
 cases? The analogous case of tubercle may help us 
 to understand. That inheritance has a large share 
 in the production of phthisis is as indisputable 
 at the present day, when the tuberculous process 
 is known to be due to the invasion of a micro- 
 organism, as it was before bacilli were discovered ; but, 
 though it is known that phthisis is influenced by 
 heredity, it is known also that the bacillus is not 
 inherited. What is inherited is a "delicacy of con- 
 stitution," a " vulnerability," a " feebleness of resist- 
 ance," such that, when the organism is invaded by bacilli 
 it has less power to attack and destroy them, they 
 more easily effect a lodgment, establish themselves 
 and multiply, than they do in the tissues of a person 
 of stronger constitution. And some cases, at any rate, 
 of insanity are closely analogous. Among the stresses 
 that do unquestionably produce insanity is that of 
 poison circulating in the blood, and supplied in the 
 pabulum presented to the nerve tissue. There is indis- 
 putable evidence with respect to some of these poisons 
 that the nerve tissue of different people has different 
 power of exclusion or of counteraction. No observation 
 is more trite than the amount of alcohol, for instance, 
 
THE CAUSES OF INSANITY. 43 
 
 which will make one man beastly drunk, will leave 
 another but slightly elevated, and have no appreciable 
 effect upon a third. And these differences in the power 
 of the nerve tissue to exclude or to neutralise the 
 alcohol that is supplied to it are derived from inherit- 
 ance. They are part of the innate constitution which 
 the individual derives from his ancestry. There is 
 therefore nothing inconsistent with experience in sup- 
 posing that similar innate and inherited differences 
 exist in the power of the nerve tissue to exclude or 
 neutralise other poisons ; and if, as is probable, many 
 forms of insanity are due to the action of poisons upon 
 the nerve tissue, the influence of inherited quality of 
 nerve tissue is easy to understand in such cases. 
 
 But although poisons are among the most powerful 
 stresses that the higher nerve regions have to with- 
 stand, and among the most frequent, they are not the 
 only ones. As we shall presently see, there are many 
 other stresses that are provocative of insanity ; but the 
 way in which inherited incapacity renders the indi- 
 vidual obnoxious to the action of poisons helps us to 
 understand the way in which incapacity, similarly 
 acquired, may facilitate the occurrence of insanity on 
 other provocation than that of poisonous food. We see 
 similar differences in the power of the nervous system 
 to resist disturbing agents, and to maintain equable 
 action, in other respects. We see that the disaster 
 which will reduce one man to despairing impotence 
 will stimulate another to energetic activity. We see 
 that the same insult which will provoke one man to 
 uncontrollable rage will be treated by another with con- 
 temptuous indifference. And these differences, again, 
 are innate, and are derived from inheritance ; so that 
 we can dimly understand how it is that a set of 
 
44 TEXT-BOOK OF INSANITY. 
 
 circumstances which will produce insanity in one man 
 will have no such effect upon another. 
 
 So widely spread and so strong is the belief in the 
 hereditariness of insanity, that proposals are frequently 
 made to limit by law the marriage, not merely of 
 persons who have been insane, but of those who have 
 insanity " in the family " ; and the expediency of such 
 marriages is a matter on which medical practitioners 
 are frequently consulted. Such proposals are imprac- 
 ticable. If marriage is to be prohibited in all cases in 
 which a clean bill of health cannot be shown for all the 
 individuals in, say, three generations, the practical 
 result would be to prohibit marriage altogether ; and 
 although the offspring of those who have been insane 
 are more likely to be insane, and to have children who 
 become insane, than are the offspring of normal indi- 
 viduals, yet it by no means necessarily follows that such 
 ill results will accrue. The children of any individual 
 who errs from the general standard of the race in any 
 respect exhibit, in the great majority of cases, a return 
 towards the standard. The children of giants are not 
 so tall, nor are the children of dwarfs so short, as 
 their respective parents ; and very many of the 
 children of the insane are as sound in mind as they 
 are vigorous in body. Even when insanity is strongly 
 prepotent in a race, and when four or five brothers 
 or sisters are insane, there is usually at least one 
 brother or sister who never shows a sign of insanity. 
 The influence of inheritance in producing insanity 
 is great, but it should not be exaggerated ; and it 
 would be a gross exaggeration to suppose that the 
 children of an insane person must necessarily be 
 insane. 
 
 There is a widespread opinion that the children 
 
THE CAUSES OF INSANITY. 45 
 
 of cousins german are more prone to insanity, and 
 especially to weakness of mind, than other people. 
 The very thorough investigations of Mr. Huth into 
 the marriage of near kin have not sufficed to dispel 
 this opinion, in the face of the occasional occurrence 
 of idiocy or insanity in the offspring of persons so 
 related. That such cases do occur is indisputable, 
 but that in very many cases the offspring of cousins 
 german are as normal and as well endowed as other 
 people, shows beyond question that it is not the mere 
 existence of blood relationship between the parents 
 that produces this effect. The truth seems to be that 
 if there is any heritable disposition in the common 
 family, whether this disposition be to phthisis, gout, 
 cancer, insanity, or what not, the inheritance in the 
 child is intensified by its derivation from both parents. 
 The same intensification would be produced even were 
 the common grandparents destitute of any such heri- 
 table disposition, if such disposition existed in both 
 of the unrelated parents of the cousins. Whether 
 the individual gets his morbid inheritance from the 
 common ancestor of his parents or from unrelated 
 ancestors makes little difference. The important 
 consideration is whether he gets the same kind of 
 inheritance inheritance of the same disposition or 
 defect from both his parents. In such a case the 
 gravity of the inheritance is more than doubled. 
 
 The stresses that produce insanity are of three 
 kinds. The first consists of those in which a dis- 
 turbing agent acts directly upon the nerve tissue of 
 the highest regions of the brain ; in which they are 
 bruised by violence, compressed by tumours, damaged 
 by inflammation, or vitiated by the supply of a 
 poison in the blood. These we will call "direct 
 
46 TEXT-BOOK OF INSANITY. 
 
 stresses."* Gross lesions of the brain, in their active 
 stage, are seldom attended by insanity in the clinical 
 sense. Meningitis, cerebral abscess, cerebral tumour, 
 concussion, fracture of the skull, wounds, lacerations of 
 the hemispheres, are attended, not by active insanity, 
 but by various depths of coma ; and coma, though 
 scientifically it is a form of insanity, and though it 
 is the form which all insanities assume at last, if 
 they go on to the end, yet, since it is not clinically 
 regarded as insanity, need not be dealt with here. 
 Although, however, in their active stages, gross lesions 
 do not produce clinical insanity, yet, if they damage 
 or destroy convolutions, this damage may be evidenced 
 in insanity when the course is sufficiently cleared up 
 for the defect of sanity to become recognisable. In 
 every large asylum there is a proportion of weak- 
 minded inmates whose defect of mind is owing to 
 gross structural defect of brain, the result of previous 
 active process. 
 
 By far the most important of the direct stresses, 
 perhaps the most important of all the stresses which 
 contribute to the production of insanity, is alteration 
 in the composition of the blood by which the highest 
 nerve regions are nourished. 
 
 Simple deficiency of nutriment reduces the efficiency 
 of the function of the nerve tissue, which exhibits 
 itself in deficiency of sanity. In starvation the 
 mind is weakened according to the degree of the 
 starvation, the attenuation of mind reaching to actual 
 unconsciousness when the starvation is extreme, and 
 
 * It should be mentioned that the term "stress" has of late 
 years been used in a sense different from that in the text, which 
 was first applied in 1890 to the agents that provoke insanity. It 
 is used to mean exercise, fatigue, exhaustion of nervous tissue. The 
 former meaning has been restored in the text. 
 
THE CAUSES OF INSANITY. 47 
 
 when the deprivation of nourishment is very rapid 
 and very great. Even when it is neither, but the 
 heredity is bad, the weakness of mind may be accom- 
 panied by active insanity. In a large proportion of 
 the cases of acute insanity that we have to treat, a 
 greater or less degree of starvation has been one of 
 the factors in its production ; and copious feeding 
 is one of the most important modes of treatment of 
 acute insanity. 
 
 ^^he deficiency in the nutritive supply of the brain 
 may be due, not to starvation, but to haemorrhage, 
 or to any other condition in which the blood is 
 impoverished; and whatever the cause of the im- 
 poverishment, the deterioration of sanity is the same, 
 provided the impoverishment is the same in degree, 
 and the resistive power of the nerve elements is the 
 same. Hence we sometimes meet with insanity, usually 
 of a very intractable type, after severe haemorrhage; 
 and in all exhausting disease there is some deteriora- 
 tion of mind deterioration which, in persons whose 
 nervous system was originally badly organised, may 
 attain to actual insanity. 
 
 More potent even than attenuation of the nutritive 
 supply to the brain is its vitiation. By introducing 
 a poison into the blood, we can produce insanity at 
 will. We can regulate the degree of the insanity 
 by the amount of poison that we administer, and we 
 can maintain the insanity as long as we please by 
 continuing the administration of the poison. Proof 
 of these statements is exhibited by every case of 
 drunkenness, by every case in which chloroform or 
 ether is administered. The insanity of acute alcoholic 
 poisoning is extremely instructive. From it we learn 
 that the rapid administration of a very large dose of 
 
48 TEXT-BOOK OF INSANITY. 
 
 the poison will produce rapid death by coma ; that 
 the rapid administration of a smaller dose will pro- 
 duce a furious mania of short duration, passing, in 
 a few hours, through coma into recovery ; that a 
 more gradual administration of several smaller doses, 
 extending over some hours, will produce an exalted 
 delirium of a milder type, passing presently into sleep, 
 and so to recovery ; that the prolonged administration 
 of quantities barely sufficient to keep up this milder 
 delirium will produce, after days or weeks, an attack 
 of acute insanity of very different form, characterised 
 neither by maniacal fury nor by jovial exaltation, but 
 by suspicion, misery, and prominent hallucinations of 
 vision, a form of insanity which is of longer duration 
 than the others, and lasts for several days ; and, lastly, 
 that the administration of still smaller quantities, if 
 prolonged for years, will give rise to yet another form 
 of insanity, a form in which the exaltation of the third 
 phase is often combined with the suspicion of the 
 fourth, and to them are added pronounced defects of 
 intelligence, and especially of memory, and in this 
 form the duration is still further prolonged. It lasts 
 for months and years, and is often irrecoverable. 
 
 The different effects of different dosage, and of 
 greater or less prolongation of the administration 
 of the poison, are not all that we learn from the 
 administration of alcohol. We learn also that the 
 manner in which the insanity is manifested depends 
 not only on the dosage and the mode of administration, 
 but upon the nature of the individual to whom the 
 poison is administered. One person becomes hilarious, 
 jovial, and braggart in his cups ; another becomes 
 sentimental, maudlin, and confidential; a third be- 
 comes suspicious and morose ; and a fourth, under the 
 
THE CAUSES OF INSANITY. 49 
 
 same administration of the same amount, becomes 
 furiously maniacal, violent, and destructive. 
 t- Alcohol is very important, because it is not only 
 one of the most frequent, but the most manageable, 
 of all the poisons which produce insanity. * The 
 number of these poisons is very large, and their 
 constitution most diverse. They include such simple 
 substances as carbonic acid, whose intoxicating effect 
 is seen in the delirium of heart disease, and perhaps 
 in that of pneumonia, and substances so complex as 
 the toxins produced by the specific organisms of 
 zymotic disease. They include foreign substances 
 introduced into the body from without, as well as 
 toxins produced within the body by variation of its 
 own metabolism, and, perhaps most deadly of all, 
 toxins produced by the co-operation of foreign agents 
 and bodily processes. Seeing how readily and how 
 frequently insanity is produced by the administration 
 of alcohol, and how very familiar we are with the 
 delirium of fevers, a form of insanity that has for 
 many years been recognised as due to the action of 
 poisons, it is a little surprising that the influence 
 of poisons in producing insanity has only recently 
 had its due importance assigned to it ; but it is not 
 at all surprising that as soon as the toxic origin of 
 insanity is fully recognised it should be exaggerated, 
 and that the claim should be made that every case 
 of insanity is of toxic origin. This is certainly not 
 the case ; but still, the role of blood-poisoning in 
 producing insanity is a very important one. It is 
 probable that it accounts for all, or nearly all, cases 
 of acute insanity ; and it is now certain that it has 
 a very large share in the production of general 
 paralysis of the insane. The nature and mode of 
 
 4 
 
50 TEXT-BOOK OF INSANITY. 
 
 origin of the poison are often very obscure. It is 
 no doubt often produced within the body by some 
 fatal variation of its own chemistry, while often it 
 is introduced from without. Disease that is due to 
 poisoning, whether the poison is introduced into the 
 body or produced within it, is usually febrile in 
 character ; it is usually accompanied by raised tem- 
 perature and other signs of fever ; but the poisons 
 that produce insanity do not usually produce fever. 
 In the delirium of zymotic disease there is, of course, 
 fever. There is fever in acute delirious mania, which 
 is probably a disease of the same class. In some cases 
 of puerperal insanity there is fever from absorption of 
 the decomposing contents of the uterus; but in the 
 great majority of cases of acute insanity which are 
 undoubtedly due to intoxication, the temperature is 
 not raised. This is a very important clinical obser- 
 vation, for occasionally the invasion of zymotic disease 
 of smallpox, scarlet fever, typhoid or other fever 
 is marked by an outbreak of acute delirium which 
 is indistinguishable from the acute insanity due to 
 other toxins, except by the temperature. A raised 
 temperature in acute insanity should, therefore, always 
 arouse suspicion of zymotic disease. 
 
 This is the most appropriate place in which to 
 enumerate sleeplessness among the provocations of 
 insanity. As with several other factors in the malady, 
 it is difficult to determine how far it acts as a cause 
 and how far it is a symptom merely. That there are 
 very many persons who habitually sleep very badly 
 lightly, intermittently, and for an insufficient number 
 of hours and who yet never come within measurable 
 distance of insanity, is certain. Equally certain is it 
 that acute insanity is often preceded for days or weeks 
 
THE CAUSES OF INSANITY. 51 
 
 by a marked and unusual degree of insomnia, and that 
 the induction of sleep often marks the first step toward 
 recovery ; but whether the sleeplessness is a cause or 
 a sign of the oncoming insanity is uncertain ; nor is it 
 very important, since in either case it is a warning, 
 and in either case it is to be dealt with in the 
 same way. 
 
 The indirect stresses that tend to produce insanity 
 are of two kinds those which arise within the limits 
 of the organism, and those which arise in the 
 commerce between the individual and his circum- 
 stances. 
 
 In the first class are included all those bodily 
 processes which make large draughts upon the stored 
 energy of the nervous system, whether the demand 
 is made by the process of growth and development, 
 by that of reproduction, by bodily or mental exertion, 
 by the processes of disease, or for recuperation after 
 illness. Any process, in short, that is generally 
 exhausting, may contribute to the production of in- 
 sanity, and d fortiori the concurrence of two or more 
 of these processes is eminently provocative of insanity. 
 
 Close observers of the development of children know 
 that their mental development proceeds, on the whole, 
 alternately with their bodily development ; that they 
 have periods in which their bodily growth is stationary, 
 while their minds develop apace, alternating with 
 periods in which their bodily growth is rapid and 
 their mental development ceases, or seems even to 
 retrograde. If, during the latter period, an injudicious 
 attempt is made to force the mental development by 
 close application to mental work, the consequence will 
 be a serious " nervous breakdown " of the nature of 
 insanity. The demand upon the energy of the brain 
 
52 TEXT-BOOK OF INSANITY. 
 
 is greater than it can supply ; it becomes so depleted 
 that it cannot carry on its current function, and the 
 depletion exhibits itself in the form of insanity that is 
 known as stupor. The same condition may result, 
 though more rarely, from excessive addiction to 
 athleticism when the mental development is very 
 active. If the combined effect of concurrent physical 
 and mental development is exhaustive, still more 
 exhaustive is the additional demand upon the energies 
 of the organism which is made by the evolution of 
 the reproductive function at puberty, and when to this 
 is added the further drain of frequent masturbation, 
 we can understand how it is that insanity, or a minor 
 disorder of the same nature, is so frequent in adoles- 
 cence, and how it is that that is the period of life when 
 stupor and hysteria are most frequent. 
 
 The dominant role of the reproductive function in 
 the life of every organism has already been pointed out 
 in the previous chapters. It has now to be noted that 
 not only is reproduction the aim and end to which all 
 life is subservient, but that reproduction and life are 
 mutually antagonistic that is to say, the full and 
 complete life-worthiness of the individual is incom- 
 patible with reproduction ; and reproduction diminishes 
 the life-worthiness of the individual so as in some cases 
 to destroy him or her altogether; and in all cases to 
 render the parent, for a time at any rate, less capable 
 of living, less apt and less competent to maintain the 
 struggle for existence. Seeing that the motive of 
 existence is the reproduction of the race, it is to be 
 expected that, when this aim is attained, existence 
 should cease, or at any rate should approximate to 
 its close. 
 
 In the first place, the addition of the reproductive 
 
THE CAUSES OF INSANITY. 53 
 
 function to the powers of the previously unproductive 
 organism is itself an occasion of disorder. The infertile 
 organism consists of a large number of organs and 
 functions co-ordinated together and acting one with 
 another in due correlation as one harmonious whole. 
 When a new set of organs and functions of dominant 
 importance has to be added to those already in 
 existence, has to be correlated with them, to be 
 assigned their place in the economy, and to be 
 allotted their share in the life, of the organism, it is 
 evident that so far-reaching and delicate a process 
 of equilibration will be very apt to fail in exactitude, 
 especially if the great co-ordinating agent, the brain, 
 is lacking in power. Hence the period of the assump- 
 tion of the reproductive function is always a period of 
 danger, and very frequently of disorder The liability 
 to disorder is, in the early stage of the assumption, but 
 small, and insanity at puberty is rare ; but the reproduc- 
 tive function is not then fully acquired. It is not until 
 after seventeen that the female is fully nubile, not 
 until after twenty that the male is fully virile, and it 
 is not until these ages that the probability of insanity 
 has to be seriously considered. It is then only that 
 the individual becomes, not merely capable physio- 
 logically of continuing the species, but awake to the 
 responsibilities of life. It is then only that the real 
 dangerous stress begins to bear upon the highest 
 regions of the brain ; and while insanity before these 
 ages is very rare, it then begins to be frequent. 
 
 The reproductive act is a great exhauster of energy. 
 It is always and of necessity inimical to life. In many 
 of the lower animals it is ipso facto destructive of life. 
 In man, while it is not thus necessarily fatal, it is 
 yet detrimental. It is exhaustive; it renders the 
 
54 TEXT-BOOK OF INSANITY. 
 
 individual less fit and less capable of resisting adverse 
 circumstances ; and, if it is repeated with undue 
 frequency, its ill effects become conspicuous. The 
 woman who has children in rapid succession becomes 
 enfeebled, anaemic, hysterical, the prey of neuralgia 
 and of many nervous maladies, an easy victim to 
 tubercle and other bacilli. The man who repeats 
 the sexual act with great frequency becomes similarly 
 etiolated and enfeebled ; and both are apt to give 
 evidence of the exhaustion of energy in neurasthenia 
 or in insanity. The connection of masturbation with 
 insanity is very close. A few years ago masturbation 
 was looked upon, it is scarcely too much to say, as 
 the most potent cause and the invariable accompani- 
 ment of insanity; but nowadays masturbation as the 
 prime and sole cause of insanity has been abandoned 
 in favour of " toxins," a very comforting word, which 
 enables us to believe that we know far more about the 
 causation of insanity than we did when we ignorantly 
 called them " poisons." In males, and especially in 
 unmarried adolescent males, occasional masturbation is 
 so extremely common that it is scarcely to be considered 
 abnormal. The same is true of older men who have 
 no opportunity for the normal gratification of the 
 sexual passion. And by those who are becoming 
 insane, or are liable to become insane, it is no doubt 
 practised more freely, it may be to great excess. But 
 insanity does not occur in people who are of sound 
 mental constitution. It does not, like smallpox and 
 malaria, attack indifferently the weak and the strong. 
 It occurs chiefly in those whose mental constitution 
 is originally defective, and whose defect is manifested 
 in lack of the power of self-control and of forgoing 
 immediate indulgence ; and when it attacks those 
 
THE CAUSES OF INSANITY. 55 
 
 who were originally normally constituted, the breaking 
 down of the power of self-control is among its first 
 effects. It would be wonderful, therefore, if mastur- 
 bation were not practised, and practised freely, by 
 those who are liable to become, or are becoming, 
 insane. And since the sexual act is in all cases 
 a very efficient cause of exhaustion and depletion of 
 energy, it cannot fail to assist the deteriorative 
 process, to hasten the onset of insanity where this 
 is impending, and to retard and impede recovery 
 where insanity is established. But to look upon 
 masturbation as the sole, or even the chief, agent in 
 the production of insanity, is to take a very exag- 
 gerated view. 
 
 In the female, indulgence in this vice is very much 
 less common than in the male, and the mere fact that 
 it is practised is primd fade evidence that the girl 
 or the woman who indulges in it has not attained 
 to the normal mental standard, but is congenitally 
 abnormal. In the female, however, the sexual act 
 is less exhausting than in the male, and while the 
 significance of masturbation as an indication of an 
 abnormal mental constitution is greater, its importance 
 as a contributory cause of insanity is much less. 
 
 While the female is less obnoxious to the deteriora- 
 tive influence of masturbation than is the male, she 
 is liable to other stresses of reproduction from which 
 he is exempt. Upon her fall the stress of pregnancy, 
 parturition and lactation, each of which may be the 
 occasion of insanity. The "longings," and equally 
 the aversions, of the pregnant woman are aberrations 
 of mind so usual that they scarcely attract attention ; 
 but any occasion on which disord er of mind, however 
 trifling, occurs in healthy and well-constituted people 
 
56 TEXT-BOOK OF INSANITY. 
 
 is an occasion on which insanity may occur in those 
 who are less healthy and less well constituted. Indeed, 
 considering how marked are the mental disorders 
 that often accompany pregnancy, the aversion to the 
 husband, the excessive caprice, the restlessness and 
 " nervousness," it is remarkable that insanity is not 
 more frequent in pregnancy, for on the whole it is 
 an infrequent occasion of insanity, only about one 
 per cent, of all the cases of insanity that occur in 
 women being associated with this condition. 
 
 The puerperal state is a much more frequent 
 
 occasion of insanity, about six per cent, of all the 
 
 cases among women occurring in connection with 
 
 childbirth that is to say, within a month or so of 
 
 parturition and when we consider all that child birth 
 
 implies, we find no cause for surprise that this should 
 
 be so. In the first place, when the child is born, an 
 
 immense readjustment of physiological processes has 
 
 to be made in the maternal organism. The great supply 
 
 of pabulum that has hitherto been made to the uterus 
 
 is now no longer needed there, can now no longer be 
 
 dealt with there, and has in part to be drafted off to 
 
 the breasts, in part to be dispensed with. The continual 
 
 stream of effete products from the nutrition of the 
 
 foetus is suddenly cut off, all the arrangements for 
 
 dealing with them are deprived of their material from 
 
 this source. No doubt the rapid involution of the 
 
 uterus supplies their place in so far as quantity goes, 
 
 but the quality is probably very different, and needs 
 
 further readjustment of excretory processes to enable 
 
 it to be dealt with. Then the process of labour is 
 
 itself a very severe drain upon the great reservoir 
 
 of bodily energy, and thus diminishes its capacity 
 
 to bring about these adjustments just at the time 
 
THE CAUSES OF INSANITY. 57 
 
 when they are needed. In addition to this, the 
 haemorrhage, frequently excessive, is of itself a cause 
 of serious stress ; and when to all these stresses is 
 added the absorption of septic matter from the 
 decomposing contents of the uterus, the wonder is, 
 not that puerperal insanity is frequent, but that it 
 is not much more frequent. In a certain proportion 
 of cases of puerperal insanity, about one-fourth, the 
 temperature is raised, and in these cases the suspicion 
 that the insanity is dependent upon sepsis is often 
 confirmed by the result of local measures directed to 
 emptying the uterus of decomposing matter and 
 sweetening its contents. But on the one hand, the 
 adoption of these measures in such cases does not 
 always produce improvement in the insanity, showing 
 that even where the temperature is raised, the origin 
 of the insanity is not wholly septic ; and on the other, 
 we know that there are poisons which produce insanity 
 without raising the temperature, so that we cannot be 
 sure that where the insanity is not septic it is not 
 toxic. 
 
 Puerperal insanity is most frequent in the first 
 fortnight after labour, and when more than a month 
 has elapsed before the outbreak, it is no longer called 
 puerperal. At this period insanity is infrequent, and 
 it is not until the later months of lactation that the 
 liability again increases. The insanity of lactation is 
 a disease of exhaustion. It occurs in women who 
 have suckled long and freely, who have had insufficient 
 food, and who have perhaps had to work hard ever 
 since they rose prematurely from their lying-in. It is 
 therefore much more frequent among poor women 
 than among the well-to-do. 
 
 The climacteric is another of those periods of 
 
fi8 TEXT-BOOK OF INSANITY. 
 
 physiological adjustment which make so severe a call 
 upon the powers of the highest co-ordinating organ. 
 The deprivation of function, no more than the addition 
 of function, can be effected without disturbing the 
 general balance among the various functions of 
 the body. This balance has to be readjusted, and the 
 equilibration is sometimes beyond the power of 
 the organism to effect, and the result is disorder 
 of the highest nerve regions on which the strain falls. 
 The climacteric period is always a period of some dis- 
 order in women. They are troubled with sleeplessness, 
 irritability of temper, despondency, loss of energy, and 
 lackadaisicalness ; and in exceptional cases these 
 aberrations are exaggerated into actual insanity. A 
 similar affliction may occur in men at about the age 
 of sixty, which is sometimes attributed to a climacteric 
 in them, though it is more usually associated with the 
 total change of habits and loss of interests arising 
 from retirement from business. 
 
 The other stresses of this class are those which 
 arise from bodily disease. In these cases the stress 
 no doubt very often belongs to the previous class, 
 and is a poison produced by the morbid process, or 
 perhaps, as in the case of myxcedema, a poison not 
 so much produced as permitted. The poison is not 
 actually produced by the morbid process, but owing 
 to this process, it is no longer neutralised, and so 
 produces its effect. Generally it may be stated that 
 every bodily disease has its effect upon the sanity, 
 even if it is only, by diminishing the full efficiency of 
 the cerebral action, to produce a mild and inconspicuous 
 weakening of the mental power ; and in many cases of 
 bodily disease the disorder of the cerebral processes is 
 considerable enough to amount to actual insanity, as 
 
THE CAUSES OF INSANITY. 59 
 
 the frequency of delirium shows us. In the majority 
 of cases, such insanities may be attributed either to 
 starvation, or to poisoning of the convolutions; in some 
 cases these two causes co-operate, as in bronchitis, 
 asthma, and heart disease ; in some cases we trace 
 the origin of the insanity to exhaustion of the 
 cerebral energy, as in epilepsy ; and in others we 
 are unable to offer a probable explanation of the mode 
 in which the insanity is brought about. Among 
 the starvation insanities may be instanced those which 
 occasionally occur in anaemia and chlorosis, and post- 
 febrile insanity, as well as that weakening of mental 
 power which is observable in every illness of long 
 standing a weakening which often escapes notice, 
 since persons so situated are not often called upon 
 for severe intellectual effort. Among the insanities 
 due to poisoning may be instanced those which occur 
 in Bright's disease, in gout, in lead poisoning, in 
 diabetes, as well as the delirium of fever, and perhaps 
 also the gloom, often deepening into melancholia, of 
 chronic dyspepsia and intestinal torpor. 
 
 Bodily disease is often connected causally with 
 insanity in the sense that the bodily malady supplies 
 the localisation, as it were, of the delusions which are 
 part of the insanity. Tinnitus aurium supplies the 
 provocation for aural hallucinations; intestinal ulcer 
 co-exists with the delusion that the bowels are ob- 
 structed ; chronic dyspepsia may suggest that there 
 is a live weasel or lobster in the stomach ; some 
 uterine affection may be at the root of a delusion of 
 pregnancy ; some vaginal irritation may so direct the 
 delusion that the patient believes she is frequently 
 raped, and so forth. 
 
 Lastly, as old age comes on, it may be attended, 
 
60 TEXT-BOOK OF INSANITY. 
 
 not by a gradual and equable decline of the faculties, 
 but by a breakdown more or less catastrophic in 
 character, which may take the form of melancholia, 
 of mania, of persistent delusions, of rapid dementia, 
 or of several other varieties of insanity. 
 
 Stresses of the third class are those which arise out 
 of the relations between the organism and its sur- 
 roundings, and may be dealt with in the order 
 proposed for the activities of conduct in the last 
 chapter. The circumstances under which these 
 stresses arise are those which arouse emotion, and the 
 more powerful the emotion aroused, and the greater 
 the suddenness with which it is aroused, the more 
 effectual is the stress in producing insanity. Stresses 
 of this class are, upon the whole, much less potent 
 than those of internal origin, which in their turn 
 are less effectual than those which have been termed 
 direct. The stresses with which we are now dealing 
 do not produce insanity except in those who are 
 already predisposed to become insane by their 
 heredity. 
 
 In the relations which directly concern the physical 
 safety of the organism, the only circumstances that 
 are capable of provoking insanity are those of fright, 
 or " nervous shock." The stress is not a fertile cause 
 of insanity, but a certain small proportion, about one 
 per cent, of all the cases that come under treatment, 
 are assigned to this cause. 
 
 Stresses arising in the circumstances under which 
 the livelihood is earned are more important. It does 
 not appear that extreme poverty is of itself provocative 
 of insanity, for we do not find that it is very prevalent 
 among those who live in penury, nor among the victims 
 of what is known as the " sweating system." But the 
 
THE CAUSES OF INSANITY. 61 
 
 apprehension of poverty, the fear of losing the means 
 of livelihood, and the descent from more prosperous to 
 less prosperous circumstances, are very efficient occa- 
 sions of insanity among those who are already predis- 
 posed by constitution to become insane. In about 
 five and a half per cent., or nearly as large a proportion 
 as can be assigned among women to parturition, 
 insanity is traceable to the stress of difficulty in 
 maintaining the standard of living. 
 
 Among the circumstances which have a certain 
 efficiency in occasioning insanity is change in the 
 mode of livelihood. When a man gives up one 
 career, and embarks upon another, when a medical 
 man turns journalist, or a solicitor is called to the 
 Bar, the revolution in the mode of life, added to the 
 anxiety as to the success of the venture, is occasionally 
 a source of insanity ; and the complete revolution 
 of habit involved in retirement from business when 
 mind and body are still active, and no provision has 
 been made for their employment in other directions, 
 is also an occasional source of disorder. The form 
 that the insanity takes in such cases is usually that 
 of melancholia with delusions of poverty. 
 
 Stresses arising in connection with the family 
 circumstances are a frequent source of disorder 
 amounting to insanity. First in order among these 
 come disappointments in love and other troubles 
 arising in the course of courtship, which account 
 for about one per cent, of the occurring cases of 
 insanity, Now and then the circumstance of be- 
 coming engaged to be married will so agitate a 
 nervous girl as to render her actually insane ; and 
 if this occurs upon engagement only, a fortiori it 
 may occur upon the occasion of marriage. There are 
 
62 TEXT-BOOK OF INSANITY. 
 
 innocent girls who are totally ignorant of what 
 marriage implies ; who are coerced into marriage 
 with men for whom they have no affection, whom 
 perhaps they positively dislike ; and who learn for 
 the first time on their wedding night what marriage 
 really means. Such cases are rare, no doubt, but 
 they actually occur, and are responsible for a very 
 small number of cases of insanity. As few are the 
 cases in which connubial excess produces insanity in 
 the husband, but such cases also occasionally present 
 themselves. 
 
 No case has been recorded, so far as I am aware, 
 of extreme unhappiness in married life being provoca- 
 tive of insanity, although it would seem a pt^iori 
 as if few stresses of the order that we are dealing 
 with could be more severe. Cases have occurred, 
 however, in which the discovery of the unfaithful- 
 ness of a wife has been followed by her insanity, 
 and other cases in which it has been followed by the 
 insanity of the injured husband. 
 
 The parental relationship is full of occasions of 
 anxiety, which are stresses that may contribute 
 to the production of insanity. Anxiety over the 
 illness of children, the strain and exhaustion of 
 nursing them, the grief over their profligacy or 
 crime, worries as to the means of supporting them, 
 are all stresses which help to produce insanity in 
 parents who are not by nature constituted to with- 
 stand exhausting emotions. 
 
 The stresses that arise out of the social relations 
 are not often sufficiently severe to provoke insanity, 
 but sometimes they have this effect. Man is a 
 gregarious animal, and cannot live a healthy life in 
 solitude. If he is compelled to live alone, there is 
 
THE CAUSES OF INSANITY. 63 
 
 much danger to his mental health, and even if he 
 does not live alone, but his social circle is greatly 
 restricted, the integrity of the mind suffers. People 
 who live in a very narrow social environment, especially 
 if their time is insufficiently occupied and their interests 
 are restricted, are extremely apt to exhibit morbid 
 traits of mind and conduct. They attach a monstrous 
 consequence to trifles; they become fretful, irritable, 
 and quarrelsome; and they are extremely apt to 
 take to drink. Drink is the curse of small com- 
 munities. Prisoners who are kept in solitary con- 
 finement have often become insane, and although 
 the causative influence of the solitude has been re- 
 peatedly denied, no one who has been deprived of 
 congenial companionship for long stretches of time can 
 doubt that the deprivation has a serious effect upon 
 the mental health. When, as in the case of many 
 criminals, the man who is subjected to the deprivation 
 is originally a feeble being without mental resources, 
 its effect is necessarily more severe ; and, in practice, 
 solitary confinement for long periods has been in most 
 civilised countries abandoned. 
 
 Not only is companionship of his fellows necessary 
 to the mental health of man, but it is of prime 
 necessity that he should secure their good opinion ; 
 and the loss of esteem, the knowledge that he is 
 reprobated and held in contempt and aversion, is a 
 stress of so severe a character that we might expect 
 to find it a frequent occasion of the onset of insanity. 
 In practice, however, we do not find it so. The 
 Jabez Balfours and Benjamin Lakes do not appear to 
 be more prone to insanity than are other criminals ; 
 and the reason may be that they are secluded from all 
 actual experience of the expression of this reprobation, 
 
64 TEXT-BOOK OF INSANITY. 
 
 and find themselves but units among a crowd of others 
 who are similarly treated. 
 
 The religious circumstances in which a person lives 
 have not, at any rate nowadays, much influence upon 
 his sanity. The tumultuous emotional experiences of 
 a " revival," as it is termed, do, not infrequently, upset 
 the mental equilibrium of the feebler folk ; and we hear 
 of them falling in trances and being subject to con- 
 vulsions under the influence of the minatory preaching 
 of some eloquent enthusiast, and cases undoubtedly 
 occur in which such experiences are provocative of 
 insanity in persons previously disposed to become 
 insane ; but, in this country at least, the number 
 of such cases is insignificantly small. 
 
PART II. 
 
 FORMS AND VARIETIES OF 
 INSANITY. 
 
 or 
 
CHAPTER V. 
 
 FORMS AND VARIETIES OF INSANITY. 
 
 BY a Form of insanity is here meant a certain aggre- 
 gate of symptoms that a case of insanity presents at 
 one time ; by a Variety is meant a specific course that 
 a case may run from beginning to end, usually com- 
 bined with an assignable cause. The distinction is 
 very important. The same variety may, and usually 
 does, exhibit different forms at different times, and 
 often the same individual will exhibit at the same 
 time the characters of more than one form. Every 
 case of insanity is an example of the form of weak- 
 mindedness, in the sense that in every case some of 
 the power of mind and some of the capabilities of 
 conduct are wanting; and in many cases the forms 
 of depression and excitement are combined with this 
 weakmindedness. A case which begins with excite- 
 ment, depression, and weakmindedness may lose, later 
 on, the two former characters, and take on the form 
 of systematised delusion ; and after remaining for 
 years in this condition, may lose the latter form, 
 and remain a case of simple weakmindedness. The 
 same form of insanity may be exhibited by different 
 varieties; thus depression appears in acute insanity, 
 in general paralysis, in circular insanity, climacteric 
 insanity, and other varieties. A form of insanity 
 
68 TEXT-BOOK OF INSANITY. 
 
 corresponds with what is called, in ordinary medical 
 phraseology, a symptom ; a variety corresponds with 
 what is called a disease, which may exhibit different 
 symptoms at different times or at the same time. 
 The Forms of insanity are as follows : 
 
 A. Weakrnindedness. 
 
 B. Stupor. 
 
 C. Depression. 
 P. Excitement. 
 
 E. Exaltation. 
 
 F. Suspicion. 
 
 G. Systematised delusion. 
 
 ii. Obsession and impulsiveness. 
 K. Moral perversion. 
 
 The Varieties of insanity are : 
 
 1. Idiocy and imbecility., 
 
 2. Dementia. 
 
 3. Stupor. - 
 
 4. Acute delirious mania. 
 
 5. Acute insanity. 
 
 6. Fixed delusion. 
 
 7. Paranoia. 
 
 8. Folie circulaire. 
 
 9. Insanity of reproduction. 
 
 10. Insanity of times of life. 
 
 11. Insanity of alcohol. 
 
 12. General paralysis. 
 
 13. Insanity of epilepsy. 
 
 14. Insanity of bodily disease. 
 
CHAPTER VI. 
 
 FORMS OF INSANITY. 
 
 A. WEAKMINDEDNESS. 
 
 WEAKNESS of mind, defect of intelligence, inefficiency, 
 and degradation of conduct in some degree, is common 
 to all forms, varieties, and cases of insanity. In most 
 cases there is some other element which is more con- 
 spicuous than the mere defect, and in accordance with 
 this more conspicuous element the form is named. 
 Mania is defect of intelligence, accompanied by so 
 much excitement that the attention of the observer 
 is absorbed by the excitement, and the defect is 
 overlooked or disregarded. Melancholia is defect 
 accompanied by so much depression that the defect 
 is masked and ignored. But it is very important to 
 remember that defect is in every case of insanity the 
 underlying disorder, upon which the others are super- 
 imposed and round which they are clustered. 
 
 Weakmindedness is most various in degree. It 
 ranges from the slight obscuration of mind and 
 diminution of conduct that accompanies severe bodily 
 illness nay, from the trifling defect that is ex- 
 perienced at the end of a tiring day down to a 
 dementia so deep that language is no longer under- 
 stood, that speech is lost, that conduct, save for a 
 few automatic movements, is altogether abolished, that 
 
70 TEXT-BOOK OF INSANITY. 
 
 intelligence and feeling seem to be reduced to a mere 
 twilight glimmer of consciousness. Beneath this 
 stage, again, is the complete dementia of coma, 
 which is the last stage of every form of insanity 
 that goes on to the end. In different individuals 
 weakness of mind ranges from the man who is just 
 below the highest grade of genius down to the most 
 degraded idiot. 
 
 By weakness of mind is often understood defect 
 of intelligence, sometimes weakness of will ; but the 
 term is used here to include a comprehensive defect, 
 involving all the powers of mind as well as of conduct. 
 The patient is not only deficient in intelligence in 
 the sense that he cannot reason acutely, and cannot 
 estimate events and existences at their proper value, 
 but he is deficient in the other powers of mind also. 
 His memory is defective, and usually when weakness 
 of the mind is acquired, the defect is of a peculiar 
 character. It concerns chiefly matters of recent 
 occurrence, and leaves the ingrained memories of 
 long-past events but little affected. The will also 
 suffers. Weakminded people are often subject to fits 
 of obstinacy, and in one form of insanity, which will 
 presently be described, intense obstinacy is the most 
 striking feature of the case ; but still, even in these 
 there is no continuity of determination. While they 
 resist to the uttermost everything that is attempted 
 to be done for them, they are incapable of adhering 
 consistently to a determinate end, and of modifying 
 the means by which this end can be attained. There 
 are, it is true, forms of insanity the suicidal, for 
 instance in which the will seems to be strengthened 
 rather than weakened, but in most forms the will 
 suffers with the other faculties. Nothing is more 
 
FORMS OF INSANITY WEAKMINDEDNESS. 71 
 
 remarkable in the demeanour of a general paralytic, 
 for instance, than the way in which he will submit 
 in his own house, and at his own table, to the 
 dictation of a stranger. Occasionally this " facility," 
 as it is called in Scotch law, is the chief defect in 
 weakness of mind. Together with the other mental 
 faculties, the emotions become weakened. The patient 
 is often much more readily moved, it is true, to a 
 display of emotion, and the display is often exag- 
 gerated, but the emotion is shallow and transient. 
 Great disasters, loss of fortune, death of friends, leave 
 them but little affected. They are easily moved to 
 anger, but their anger is short-lived. They are 
 easily moved to tears, but they are incapable of 
 lasting grief. 
 
 With the decay of mind goes decay of conduct. 
 Of the higher forms of conduct they are incapable. 
 As has been pointed out elsewhere, insane persons 
 are always deficient in the highest developments of 
 conduct, in politeness, courtesy, and all that is implied 
 in the term "manners." They are objectionable at 
 their meals, and selfish and inconsiderate in all things. 
 Then, too, whatever the nature of their occupation, 
 they can no longer conduct it with full capability. 
 Their family relations become impaired ; in some 
 department of conduct, if not in all, they exhibit 
 defect; and the deeper and more confirmed the 
 malady, the more departments of conduct are found 
 defective, and the greater the defect in each. In the 
 deepest grades of weakmindedness, mind and conduct 
 scarcely exist, and the individual leads a vegetative 
 existence, in which every function of conduct has to 
 be performed for hi in. 
 
72 TEXT-BOOK OF INSANITY. 
 
 B. STUPOR. 
 
 Stupor is a peculiar and well-marked form of insanity 
 which is not very uncommon, but as it is exhibited 
 almost exclusively by the variety of insanity of the 
 same name, its description is left, in order to avoid 
 repetition, until that variety of insanity is reached. 
 Stuporose symptoms, in the shape of cataleptic plasticity 
 and the peculiar vacancy of mind and countenance, are 
 not very infrequent in the melancholic type of acute 
 insanity, to which stupor is allied ; but with this excep- 
 tion the form and the variety of in sanity are in this case 
 identical. 
 
 c. DEPRESSION. MELANCHOLIA. - 
 
 In stupor, the state, as a describable morbid alteration 
 of mind and conduct, remains fairly constant throughout 
 the course of the malady, so that the form of the 
 insanity as an existing state and the variety as running 
 a certain course are identical. The form that we now 
 have to describe is very well characterised and very 
 frequent. It is perhaps the commonest of all forms of 
 occurring insanity, but it is not a disease in the sense 
 that it follows any uniform sequence of events. It is a 
 state which may exist at some stage or other in the 
 course of almost all the varieties of insanity, but it is 
 not itself a variety in the sense in which that term is 
 used here. It may be present in stupor ; it may 
 be present in acute insanity, in fixed delusion, in 
 systematised delusion, in folie circulaire, in alcoholic 
 insanity, in general paralysis, and in the insanity of 
 epilepsy, and indeed in any variety of insanity ex- 
 cept acute delirious mania ; but in none of these 
 cases is it a characteristic or essential, nor is it usually 
 
FORMS OF INSANITY MELANCHOLIA. 73 
 
 an enduring feature in the malady. It may present 
 itself at one time or another in any of these diseases, 
 but it is not itself a disease ; rather it may be regarded 
 as a symptom which is frequent in insanity than as a 
 variety of insanity, a symptom which may exist in the 
 absence of insanity. 
 
 By melancholia we mean a feeling of misery which 
 is not justified by the circumstances of the individual, 
 and, as has been said, this feeling occurs under very 
 various conditions. It may be unattended by any 
 other disorder, and when it so occurs, it is not 
 to be regarded as insanity. " I feel wretched," 
 says the patient. " I feel depressed and miserable, 
 and for the life of me I cannot tell why. I 
 have had no misfortune, my circumstances are good, 
 my business is prosperous, my family relations are 
 happy ; but yet I feel so depressed. I suppose 
 it is the liver." And if by " the liver " he means 
 chronic dyspepsia and constipation, he is very often 
 right. If we can relieve the dyspepsia by treatment, 
 we find that, as it improves, the mental depression 
 passes away. Such cases, in which the depression of 
 spirits is the only mental disorder, are called cases of 
 simple melancholia. There are people, usually the 
 subjects of chronic dyspepsia and constipation, who pass 
 a great part of their lives in this condition . They are 
 usually people of spare habit, dark hair, and sallow skin. 
 They haye little energy, and less fortitude. The little 
 annoyances of life trouble them more than they trouble 
 other people. They " take things to heart " ; they 
 worry over little things ; they are always " down on 
 their luck." Fortune, they think, has a special spite 
 against them. Their lives are passed in wailing and 
 complaining, and they radiate discomfort as a fire 
 
74 TEXT-BOOK OF INSANITY. 
 
 radiates heat. If a real calamity overtakes them, they 
 sink under it ; and then they are very apt to commit 
 suicide, either before or after they have become acutely 
 insane ; and often their chronic melancholy deepens 
 into insanity without the stress of any obvious calamity. 
 They form one class of those from whom the ranks 
 of the insane are recruited. 
 
 Melancholia, except in mild degree, does not long 
 remain a simple disorder. As soon as the misery 
 deepens, becomes intense, becomes pronounced, it 
 is attended by definite delusion ; and the delusion 
 is always of a character consonant with the insanity. 
 It is always of the nature of diminished worthiness 
 and diminished capacity. In the delusions that 
 accompany melancholia there is always this note 
 of personal un worthiness and personal incapacity, 
 but curiously, as it appears, there is rarely diminu- 
 tion of personal consequence. On the contrary, the 
 self-consequence is often exaggerated, and exaggerated 
 to a monstrous degree, but it is a mistake to suppose 
 that it is always so. The feeling of personal consequence 
 is sometimes diminished. In a few cases one is met 
 by the protest, " Don't trouble about me ; I am not 
 worth troubling about. All these things are too good 
 for me. Leave me to the fate which I deserve." 
 But usually, as in delusions that will be mentioned, 
 the personal consequence is exaggerated. 
 
 The delusions of pure melancholia are chiefly 
 religious delusions, delusions of wrongdoing, and 
 delusions of poverty. There is, in addition, a very 
 large class of delusions of personal repulsiveness, but 
 where these exist the case is not usually pure 
 melancholia, and is often not melancholia at all. 
 Such delusions are usually associated with the idea 
 
FORMS OF INSANITY MELANCHOLIA. 75 
 
 of persecution, and the cases in which they exist 
 graduate into paranoia, and for the most part are 
 pure paranoia, in which melancholy is replaced by 
 indignation. Finally, in many cases of melancholia 
 there are delusions of impending evil, often at the 
 hands of others, which, although they are in a sense 
 delusions of persecution, are yet very widely different 
 from the delusions ordinarily so called. 
 
 Religious delusion and delusion of wrongdoing are 
 closely allied, and may be taken together. The 
 patient is convinced that he has sinned, sinned deeply 
 and irremediably. Very often he has committed 
 " the unpardonable sin," an expression which different 
 patients interpret very differently. By some is 
 understood a hasty objurgation, by some deliberate 
 blasphemy, and very many of the unpardonable 
 sinners mean that they have been addicted to 
 masturbation. From having sinned to being damned 
 is but a short step, and the majority of these 
 melancholies with religious delusions are, in their 
 own estimation, in this parlous state. Delusions of 
 wrongdoing are very numerous and very various. 
 Sometimes the patient deludedly believes that he has 
 robbed a bank, or committed a murder, or done some 
 other act of real wrongdoing. Others, again, attach 
 the stigma of wrong to some innocent act which they 
 really have done, and are overwhelmed with remorse 
 at having called some one a harsh name, or shut a 
 door in a manner which seems to them felonious, 01 
 thought something that they ought not to think. 
 They have brought misfortune upon all their family, 
 all their countrymen even, by some trifling neglect or 
 some small peccadillo. Sometimes they are convinced 
 that they have done wrong, but for the life of them 
 
76 TKXT-BOOK OF INSANITY. 
 
 they cannot think what the wrong act was. Delusions 
 of these classes are usual in the melancholia of early 
 life, especially the religious delusions, while delusions 
 of wrongdoing may exist at any age. 
 
 Delusions of poverty are unknown in the young, are 
 rare in women, and are most often met with in men 
 after the age of fifty. They are often very extreme. 
 A man who lives in luxury and possesses an ample 
 income will see the workhouse staring him in the 
 face, and will go and inspect it to see what his future 
 quarters are like. He will refuse food because he 
 cannot afford to pay for it, or commit suicide to save 
 his relatives from the burden of maintaining him. 
 
 Delusions of disease, malformation, or repulsiveness 
 are less common in melancholia than those of the 
 varieties enumerated above, and, as has already been 
 stated, are not, as these are, confined to cases of 
 melancholia. At the one end they graduate into 
 hypochondria, at the other into paranoia and fixed 
 delusions. The patient is subject to syphilis ; or his 
 bowels are stopped and nothing ever passes through 
 him ; he cannot digest his food ; he is impotent ; 
 he cannot pass water. In such cases the condition 
 is allied to hypochondriasis, and they are often 
 called hypochondriacal melancholia. Or the patient 
 may declare that his brain has been removed, that 
 he has no bowels, that he has a weasel, a rat, a 
 dog, inside him, that he has no back to his head, that 
 his legs are of glass, and so forth. Usually such 
 delusions are not accompanied by a corresponding 
 degree of depression, often they are not accompanied 
 by any depression at all. They then fall into the 
 class of fixed delusions, and are excluded from that 
 of melancholia. Then there are the delusions of 
 
FORMS OF INSANITY MELANCHOLIA. 77 
 
 malformation and repulsiveness. The patient believes 
 that the nose is too large, that he has horns, that 
 he has a loathsome skin disease, that he is leprous, 
 and so on, and these patients also are usually but 
 little melancholic, at any rate after the first inception 
 of the delusion. The important aspect of this form of 
 delusion is that it leads to or is associated with the 
 notion that people are talking about it, that they 
 notice it, that they smile at it, that they jeer at the 
 patient in consequence of it. This, again, is not 
 melancholia at all ; it is persecutory delusion. 
 ^The last class of delusions witnessed in melancholia 
 are those which are persecutory in form, though they 
 are very different from the delusions of persecution 
 which are the prominent features in paranoia, and 
 the difference is that, while in the latter the delusions 
 arouse indignation and an intolerable sense of injury 
 and wrong, in melancholia they produce no such 
 effect. Very often the punishment is regarded as 
 only too well deserved ; and, if not so regarded, still 
 it is not resented. It gives rise to efforts to escape, 
 which often take the direction of suicide ; to panic 
 and horror; to misery the most profound and appre- 
 hension the most terrible; but it never provokes to 
 retaliation. The melancholy patient who thinks that 
 the police are after him, that he is to be put in prison, 
 condemned to penal servitude, hanged or otherwise 
 killed, cut into little bits, boiled in oil, starved to 
 death, and so forth, will seek refuge from his im- 
 pending fate in voluntary death, will interpret the 
 efforts of those who prevent him as part of the persecu- 
 tion to which he is subjected, and will struggle violently 
 with them in consequence ; but he will never retaliate 
 upon them. He will never take the initiative in an 
 
78 TEXT-BOOK OF INSANITY. 
 
 assault upon them. He will wail in his misery, and 
 wonder what he has done to deserve such a dreadful 
 fate ; but he will never complain with bitterness of the 
 injustice, nor harbour revenge against his persecutors. 
 It is in these respects that these delusions, persecutory 
 though they are in character, differ from the " delusions 
 of persecution " of the paranoiac. 
 
 The conduct of the melancholic is usually consonant 
 with the depression which he feels and the delusions 
 that he entertains. In simple melancholia it is merely 
 diminished. The patient suffers, and complains of 
 suffering, from a diminution of energy. Exertion 
 is painful to him, and great exertion is impossible. 
 He sits and lounges about, he is incapable of con- 
 ducting his business, he cannot interest himself in 
 reading or other occupations. If he is compelled to 
 get up and go for a walk, he often shows by his profuse 
 sweating and his feeble pulse that his disinclination 
 for exertion is not mere laziness, but is a real inability. 
 If his depression is accompanied by delusion, his 
 conduct is modified accordingly. 
 
 The sense of personal im worthiness is sometimes so 
 extreme that the patient not only thinks that he 
 ought not to live, and endeavours to put an end to 
 his life, but that, so long as his existence continues, 
 he refuses to allow himself the ordinary comforts of 
 life, and endeavours by every means to mortify his 
 flesh. He refuses delicate food, and if he consents to 
 eat at all, he demands offal and leavings. He refuses 
 the comfort of a bed, and is> he consents to lie down 
 at all, he lies on the bare floor. He will tear up his 
 clothes because he is only fit to wear rags, he will 
 refuse to wash because washing is too good for him. 
 
 If the delusion is of sin, he bemoans himself and 
 
FORMS OF INSANITY MELANCHOLIA. 79 
 
 prays for forgiveness, or practises some self-imposed 
 penance. If he is an unpardonable sinner, for instance, 
 and identifies this sin with masturbation, he may 
 attempt, and even effect, castration. If his delusion 
 is of crime, he may, and such patients very often do, 
 give themselves up to the police and accuse themselves, 
 or he may refuse to associate with his family, or leave 
 his home and settle in some squalid surroundings under 
 the belief that he is not fit to associate with his family. 
 If his delusions are of poverty, he may, as already 
 stated, refuse food on the ground that he cannot afford 
 it, or he may sell his property at some absurd sacrifice 
 in order to secure a remnant to live upon. The 
 colouring of unworthiness in such cases clings, not 
 only to the patient himself, but to his belongings. 
 He is not only himself a useless, worthless being, who 
 is no good, but his business is valueless, his invest- 
 ments are rotten, his connection is narrow and poor, 
 and his banking account a fraud. If the delusion is 
 hypochondriacal in character, then he goes, as hypo- 
 chondriacs do, from one physician to another with the 
 story of his ailments, he measures his urine, he 
 examines his faeces, he weighs himself several times 
 a day, and he takes physic without end. Lastly, if his 
 delusion is persecutory in character, he is often driven, 
 by the impulse of panic, to the wildest acts. These 
 are the patients who jump out of windows, who throw 
 themselves in front of railway trains, who leap off 
 bridges, who cut their throats, who blow out their brains, 
 who commit suicide by sudden impulsive violence. 
 
 The bodily condition in melancholia varies much. 
 In many cases there is nothing discernibly wrong with 
 the bodily health, and these are cases of mild degree 
 or of long duration; usually, however, melancholia 
 
80 TEXT-BOOK OF INSANITY. 
 
 is associated with loss of flesh, with constipation and 
 with dyspepsia. The loss of flesh may be steadily 
 progressive in spite of copious feeding, and the patient 
 may become extremely emaciated and die, apparently 
 of starvation, although he has been fed abundantly 
 throughout the illness. The constipation and disorder 
 of digestion point to intoxication from absorption of 
 decomposing matter from the gastro-intestinal surface ; 
 and in some cases the contents of this cavity are 
 incredibly foul-smelling and offensive. In such cases, 
 if the stomach be washed out, the extracted matter is 
 intolerably foul. The complexion is often muddy, 
 and the tongue flabby and coated. The temperature 
 is never raised and is sometimes below normal. The 
 pulse is small and feeble to the touch, but the blood 
 pressure is found by measurement to be increased. 
 
 Melancholia shades off into other forms of insanity. 
 We have already seen how in one form it is allied 
 to stupor. In acute insanity it often accompanies 
 maniacal excitement. It often accompanies, and more 
 often is confused with, fixed delusion, a delusion of this 
 class which endures for years, and which is of a charac- 
 ter to provoke and justify depression such a delusion, 
 for instance, as that the brains have been removed 
 or the bowels stopped being accompanied at first by 
 depression. After these delusions have become fixed 
 and have endured for years, the expression of melan- 
 choly may still remain, but we cannot doubt, from 
 the unconcern with which such people go about their 
 work, from the heartiness of their appetites, and from 
 the absence of all reference to the delusion unless 
 attention is called to it, that the expression of melan- 
 choly is merely the continuance of a habit, and does 
 not correspond with any actual feeling of melancholy 
 
FOE MS OF INSANITY-EXCITEMENT. 81 
 
 now present in the mind. The connection of deluded 
 melancholy with, and its distinction from, persecutory 
 delusion, have already been pointed out; and it is 
 now to be added that melancholia is a phase of folie 
 circulaire, and that it is very common in insanity from 
 alcohol and in general paralysis. It is very often the 
 form of insanity exhibited by the insanity of the 
 puerperium, of lactation, and of the climacteric ; and 
 it is the usual form of the insanity of starvation and of 
 phthisis. 
 
 a EXCITEMENT. 
 
 States of excitement scarcely need description ; their 
 name characterises them. What we mean when we 
 say that a man is excited is that his movements are 
 excessive excessive in amount, excessive in rapidity, 
 excessive in emphasis. We mean that he talks more 
 than he should do more continuously, more loudly, 
 more rapidly, and more emphatically ; that he ges- 
 ticulates in excess ; that all his movements exhibit 
 the same excess in comparison with the movements 
 on the same occasion of the unexcited man. In the 
 excitement of insanity there is more than this. The 
 excitement may, as in a sane person, arise upon 
 provocation only, last its time, and burn itself out ; 
 and in this case it is excessive while it lasts. But 
 not infrequently it endures : it lasts all day, and 
 encroaches upon the hours usually given to sleep, 
 or perhaps absorbs them entirely. It needs no pro- 
 vocation to start it; or, if it appear to begin upon 
 provocation, and to be from time to time intensified 
 and continued, it is upon provocation that would not 
 be provocation to a sane person. 
 
 6 
 
82 TEXT-BOOK OF INSANITY. 
 
 Excitement may inspire and characterise conduct 
 of the most different grades of elaborateness, and 
 may be of the most various degrees. When it is 
 exhibited in the higher grades of conduct, its subject 
 rises early, full of schemes of business or pleasure. He 
 fusses noisily about the house, indifferent to his dis- 
 turbance of other people's slumbers. He is very 
 impatient of delay : he cannot wait a minute for 
 anything that he wants, and if it is not forthcoming 
 on the instant, he flies into a rage. The course of 
 the post is not expeditious enough for him. He 
 sends his letters by telegraph, and his letters are 
 extraordinarily numerous. They would be numerous 
 in any case, but their number is doubled, and more 
 than doubled, by the frequent changes of his mind, 
 and by the impulsiveness with which he acts upon 
 every passing whim. He determines to make some 
 purchase, probably a very unnecessary one, but one 
 for which he can adduce twenty plausible reasons, 
 and he writes to tell his solicitor that he will call 
 the next morning. Scarcely is the letter posted 
 when he sees that he will attain his object more 
 quickly by asking his solicitor to lunch. He tele- 
 graphs accordingly. Before his messenger returns, 
 it occurs to him that he had better ask the vendor 
 to lunch also. Another telegram is despatched, and 
 since he cannot entertain more than one visitor at 
 his club, another must be sent to the solicitor to 
 announce the change to an hotel. Then he remem- 
 bers that he has been drawing heavily of late on his 
 banking account, and that he may not have the 
 necessary funds available. Another telegram to the 
 bank. But if there are insufficient funds in the bank, 
 he will have to sell stock to raise the funds : another 
 
FORMS OF INSANITY-EXCITEMENT. 83 
 
 telegram to his broker. Then lie determines that 
 it will be better to pledge the stock to the bank rather 
 tl.au to sell it. More telegrams to the broker and 
 the bank. The broker won't like the contradictory 
 orders never mind ; ask him to dinner ask them 
 all to dinner. Put off the lunch and have a dinner 
 instead, and ask the solicitor, the vendor, the banker, 
 and the broker. Yes, and why not Smith and 
 Jones and Kobinson as well ? More telegrams ; and 
 then, since two out of three of the invited guests 
 decline, the whole thing is postponed, also by tele- 
 graph. Meantime, in the intervals of telegraphing, 
 his hands have been full. He has been constantly 
 ringing the bell and giving orders giving them, 
 modifying them, and countermanding them con- 
 stantly wanting something fresh, running up and 
 down stairs, writing letters, haranguing this person 
 and that, flying into a rage upon the slightest oppo- 
 sition, tearing the bell down on the slightest delay, 
 and talking almost incessantly. This is a fair descrip- 
 tion of the conduct of a person who exhibits, on a 
 high level of conduct, a moderate degree of excitement ; 
 and conduct of this kind is very usual in the earliest 
 stage of general paralysis, though it is by no means 
 confined to cases of this malady. 
 
 Excitement on a very low level of conduct is 
 exhibited by the lunatic who howls all through the 
 night, who strips himself naked and ramps about 
 his room, hammering at the door and walls, clapping 
 his hands, shouting, singing, swearing, raving, laugh- 
 ing, crying ; and between the simplicity of such 
 conduct and the elaborateness of that described above 
 there is every degree, and every degree exists also 
 in the amount of excitement exhibited. 
 
84 TEXT-BOOK OF INSANITY. 
 
 "Excitement" and "mania" are not quite con- 
 vertible terms, but mania is always excitement, 
 though there are degrees of excitement so mild, or 
 levels of excitement so high, that they do not attain 
 to those of mania. By mania is meant a considerable 
 degree of excitement upon a low or middle level. 
 Conduct so elaborate as that of the first case described 
 above would not be called maniacal. It is excitement 
 merely, and it falls short of mania because of its 
 elaborateness ; because, although it is ill-adjusted to 
 the circumstances of the individual, yet it is not very 
 widely out of adjustment. But if, instead of arranging 
 a dinner with his solicitor and banker and broker, and 
 Smith and Jones and Robinson, he were to despatch 
 his telegrams of invitation to the King and the 
 German Emperor, and the Czar of Russia and the 
 President of the United States, then activity, being 
 equally excessive upon a lower level exhibiting a 
 more plentiful lack of appreciation of his own cir- 
 cumstances and of the proper mode of dealing with 
 them we should consider that it exceeded the bounds 
 of mere excitement and became actual mania. And 
 from this level, over-activity remains mania all the 
 way down to the pure automatism of screaming and 
 raving and hammering at the wall, from which the 
 patient cannot be diverted by any ordinary effort to 
 distract his attention. 
 
 The term " mania," like the term " melancholia," 
 with which it is often contrasted, connotes a statical 
 " form " of insanity that is to say, a state of things 
 exhibited at one time, which may occur in the course 
 of any of the varieties of insanity. But whereas 
 " melancholia " means a state of mind, u mania" means 
 a phase of conduct. It means excitement, or over- 
 
FORMS OF INSANITY EXALTATION 85 
 
 activity, at a low level of conduct. It does not 
 mean a " variety " of insanity, in the sense that it 
 originates in a certain way, runs a typical course, 
 and has a definite conclusion. Like melancholia, it 
 should rather be regarded as a symptom occurring 
 in many varieties of insanity than as a variety in 
 itself. 
 
 E. EXALTATION. 
 
 Exaltation is often combined with excitement, and 
 often exists without a trace of excitement. It is not 
 a phase of conduct, but purely a mental condition, 
 and is the reverse of melancholia. It resembles 
 melancholia in that it may be " simple " that is to 
 say, unattended by delusion or it may be accompanied 
 by delusion of certain types. 
 
 Simple exaltation is much less common than simple 
 melancholia. It is not at all uncommon to meet with 
 people who feel a misery which they know to be 
 unreasonable and unjustified by their circumstances, 
 but it is rare to meet with a person who has a feeling 
 of elation which he knows to be unreasonable and 
 unjustified. As the note of. melancholy feeling is 
 the conviction of personal unworthiness and personal 
 incapacity, so the note of exaltation is the convic- 
 tion of increased worthiness, increased capacity, and 
 increased consequence. As the conviction of the 
 melancholic is of sin, so that of the exalted patient 
 is of self-righteousness ; as the delusion of the one is 
 that he has done wrong and committed crime, so that 
 of the other is that he has conferred, or intends to 
 confer, untold benefits on his fellows ; as the terror 
 of the one is actual or impending poverty, so the 
 
86 TEXT-BOOK OF INSANITY. 
 
 exaltation of the oilier is in iho porses-ion or the 
 promise of wealth; while the one deplores his incom- 
 petence, his disease, his repulsiveness, his unworthiness, 
 the other glories in his capacity, both bodily and 
 mental, in his strength, his beauty, his skill, his 
 health, his attractiveness. In all respects the two 
 are. exactly antithetical. 
 
 A low degree of exaltation is often seen in the 
 early stage of drunkenness. After a convivial dinner, 
 a man becomes hilarious : he feels jolly ; his laughter 
 is easily excited, especially by his own rather feeble 
 jokes ; he feels unusually " fit " ; he will venture to 
 make a speech for the first time in his life; he will 
 undertake a walking tour, a bicycle race, that he 
 would, when sober, know to be far beyond his powers ; 
 he will challenge the champion billiard or golf player 
 to a match, and bet upon his own success. Now is 
 the time to get a subscription out of him. He 
 is generous, benevolent, expansive ; and } T OU can, 
 without much difficulty, elicit his opinion that he 
 is a very Lovelace among the fair, he is such a 
 captivating fellow ! 
 
 More exaggerated cases of exaltation proceed along 
 all these lines together, or along only one or a 
 few of them. In general paralysis, a man is at 
 once wealthy beyond the dreams of avarice ; his 
 generosity and charity are on a par with his im- 
 measurable wealth ; his personal capacity and attrac- 
 tiveness are such as no mythology ever attributed 
 in strength to Hercules or Samson, in wisdom and 
 knowledge to Solomon or Aristotle, in beauty to 
 Apollo or Adonis; but in many cases the exaggeration 
 is in one direction only. The patient lays claim to 
 righteousness, or even to Deity, but not to wealth 
 
FORMS OF INSANITY-EXALTATION. 87 
 
 or strength. Or he is absorbed in contemplation of 
 his millions, but lays no claim to personal superiority ; 
 and so on. It is, however, in one or more of the 
 five respects that have been mentioned that his 
 exaltation is displayed. 
 
 While the melancholic is the greatest of sinners, 
 the exalted patient whose delusions have a religious 
 cast seldom contents himself with a position among 
 the elect and a certitude' of salvation. He aims at 
 higher things. He is either the Son of God or he 
 is the Deity Himself. Or his exaggerated sense of 
 his own worthiness is shown in mundane titles. He 
 is lord, duke, prince, king, emperor, and has, besides, 
 a score of fantastic titles never heard before. 
 
 Antithetical to the delusions of crime of the 
 melancholic are the delusions of benefaction of the 
 exalted. He abolishes poverty by the simple ex- 
 pedient of giving everybody a thousand a year. For 
 the small service of handing him a cup of tea, or 
 even for the asking, or because he likes the look of 
 you, he will present you with a cheque for 10,000, 
 written, it may be, on a dirty bit of newspaper. He 
 will give away to strangers his most cherished 
 possessions the heirloom picture of his grandfather 
 the mayor, the cups that he won in athletic sports 
 at college, his favourite pipe, even his dog. He is 
 fall of benevolent schemes for improving the condition 
 of the poor; he will put an end to war by casing 
 ships in indiarubber; and so forth. 
 
 As common as the assumption of superlative titles is 
 the assumption of superlative wealth. Of all exalted 
 or grandiose delusions none are more frequent than 
 those of great possessions : millions and thousands of 
 millions in money, land in provinces and whole 
 
88 TEXT-BOOK OF INSANITY. 
 
 countries, streets and towns of houses, jewels in 
 bucketsfnl nay, one patient proposed to pave all 
 the streets of London seventeen feet thick with 
 diamonds fleets of ships, palaces, immeasurable 
 wealth of every kind. Allied to these are the 
 grandiose delusions of family scores of wives and 
 hundreds of children. 
 
 Either along with such delusions as the foregoing, 
 or held independently of them are delusions of 
 increased capacity. The patient is the greatest 
 poet, the greatest traveller, the greatest statesman, 
 the greatest inventor, mechanician, architect, painter, 
 engineer, cricket player, orator, or what not, that the 
 world has ever seen. He can beget a hundred children 
 in a night ; he can knock do\vn a house at a blow ; 
 no task is too great, no endurance too extreme, for his 
 powers ; and his magnificence extends to all his 
 possessions. His house is the most exquisite, his wife 
 the most beautiful, his children the cleverest, his 
 business the most profitable, his garden the most 
 fruitful ; everything belonging to him is superlative of 
 its kind. 
 
 Antithetical to the persecutory delusions of the 
 melancholic are the delusions of the megalomaniac 
 that he is to be knighted, ennobled, that he is to 
 be called to the throne, that new titles are invented 
 for him, that all the men worship his intellect, and 
 all the women are in love with his beauty. 
 
 The conduct of the megalomaniac, like that of the 
 melancholic, is sometimes consonant with the exalta- 
 tion that he expresses and with the delusion that 
 he entertains ; often, however more often, perhaps, 
 than with delusions of depression the conduct is 
 out of all relation with the delusion, and is scarcely 
 
FORMS OF INSANITY EXALTATION. 89 
 
 coloured by it at all. There are cases in which the 
 jovial or dignified or pompous aspect and demeanour 
 of the patient shows that his delusion is a veritable 
 motive to conduct ; and this indication is corroborated 
 by his more definite acts. If his delusion is of wealth 
 and of benevolence, he gives away thousands with 
 unsparing hand. Every scrap of paper that he can 
 pick up becomes a cheque for a fabulous amount, and 
 is given freely to the first passer-by. If his delusion 
 is of increased capacity in any department of skill, 
 he will attempt to exhibit it. He will insist upon 
 showing the professional cricketer or billiard player 
 how to play the game, the professional artist how 
 to paint, the professional musician, to perform. He 
 will write reams of doggerel which he calls poetry, and 
 which he will read to whomsoever he can get to listen. 
 Does he think he can jump over a house or knock 
 it down with a blow? he will stand before it and 
 make the endeavour, nor will he be in the least dis- 
 concerted at his failure. 
 
 In many cases, however and, as in delusions of 
 depression, these are cases of fixed delusion the 
 deluded belief has astonishingly little influence upon 
 conduct. In every large pauper asylum there are 
 queens of England who see no incongruity in spending 
 their lives at the washtub ; kings, emperors, and gods 
 who pass their time in laying tables, scrubbing floors, 
 and carrying coals ; whose delusions have practically 
 no influence upon their lives, and would not be sus- 
 pected were they not elicited by questions ; who 
 subserviently obey the attendants, and address them 
 as " miss " and '* sir." The very man who has just 
 boasted to you of his countless millions and offered 
 you a substantial share of them, will beg obsequiously 
 
90 TEXT-BOOK OF INSANITY. 
 
 for sixpence to buy a bit of tobacco, and recognise no 
 incongruity in so doing. 
 
 The bodily condition in cases of grandiose delusion 
 is usually good. In fixed delusions of this character 
 the patient is usually hale and hearty, lives to a good 
 age, and maintains his health. When grandiose 
 delusions occur in the course of general paralysis, 
 the muscular condition is usually excellent, even 
 though the paralysis progresses rapidly. The hair 
 and nails grow fast, the digestion is good, the appetite 
 often ravenous, and the bowels regular. 
 
 Exaltation is exhibited in most varieties of insanity : 
 in acute insanity ; in fixed delusion ; it forms one phase 
 of folie circulaire ; in general paralysis of the classical 
 type its most extreme instances are found ; it is 
 sometimes seen in alcoholic insanity ; is rarely com- 
 bined with epilepsy. In systematised delusion there 
 is always an undercurrent of grandiosity, in the 
 exaggerated importance which the patient attributes 
 to himself, and the exaggerated position which he 
 gives himself in the scheme of the universe, but the 
 delusions of increased worthiness and increased com- 
 petence to which the term " exaltation " is here limited 
 are never seen in systematised delusion. 
 
 F. SUSPICION. 
 
 This is a fairly well characterised form of insanity, 
 and not an infrequent one. It is characterised by 
 its title. The subjects of it are the prey of unreason- 
 able and unfounded suspicion. As with other forms 
 of insanity, a certain degree of it is often seen in 
 sane persons ; but it occurs in the sane, not as a 
 temporary alteration of character as depression, 
 
FORMS OF INSANITY SUSPICION. 91 
 
 exaltation, and excitement are apt to occur upon 
 occasion but as a permanent type of character per- 
 taining to the individual through all his moods ; 
 and consonantly with this we find that when it occurs 
 in insane exaggeration, it is extremely intractable and 
 irrecoverable. There are plenty of sane persons who, 
 whenever they lose a thing, suspect that it has been 
 stolen ; whenever anything is broken, suspect that it 
 has been done purposely ; when a friend passes without 
 observing them, suspect that they have been inten- 
 tionally "cut"; who place the worst interpretation 
 upon the acts of all around them, and are on the 
 alert to detect .slights that were never intended, and 
 discover insults in the most innocent speeches. In 
 insanity of suspicion the same thing happens, and 
 happens to an exaggerated degree. The subjects of 
 it suspect every act of everybody, and suspect even 
 inanimate things. If you ask them how they do, they 
 see some sinister motive in the question, and it enrages 
 them. Every proposal that you make to them is re- 
 jected, from suspicion of its object. The man suspects 
 that his wife is unfaithful, the woman that her husband 
 goes astray. The business man suspects that his 
 partners are trying to swindle him. Commonest of 
 all is the suspicion that the food is poisoned. 
 
 The conduct of persons with this form of insanity 
 is such as might be expected from its character. 
 They withdraw from companionship, they shrink 
 from contact with their fellows, they become soli- 
 tary, silent and sullen, irritable and depressed. 
 Smarting under their fancied injuries, they some- 
 times become violent; and as suspicion of poisoning 
 is the most frequent mental peculiarity, so refusal of 
 food is the most constant feature in conduct. 
 
92 TEXT-BOOK OF INSANITY. 
 
 The bodily condition in insanity of suspicion most 
 often exhibits signs of phthisis, since it is in the 
 insanity of phthisis that suspicion is most frequently 
 and most prominently exhibited. 
 
 Suspicion is evidently closely allied to the following 
 form of insanity systematised delusion as well as 
 to depression, with which it is often associated. It 
 differs from the former in the absence of systematisa- 
 tion. The patient is suspicious, indeed, of every one 
 and everything, but while he suspects that everything 
 or anything may be designed to injure him, he does 
 not refer this design to any individual, or body of 
 individuals, or occult influence. He looks upon the 
 individual instances of persecution as isolated occur- 
 rences, each of which is indeed designed to injure him, 
 but which are not all bound together as part of a 
 comprehensive plot by which the whole universe is 
 combined to persecute him. It often presents the 
 further difference that the suspicious lunatic is sus- 
 picious only, and is not completely convinced of the 
 adverse intention, while the subject of systematised 
 delusion is absolutely certain beyond the shadow of 
 doubt. 
 
 G. SYSTEMATISED DELUSION. 
 
 This form of insanity is seen in one variety only 
 of the malady viz., in paranoia. Its description will 
 therefore be deferred until that variety is dealt with. 
 
 H. OBSESSION AND IMPULSIVENESS. 
 
 There is a natural affinity between obsession and 
 impulsiveness which, renders it appropriate to describe 
 
FORMS OF INSANITY IMPULSIVENESS. 93 
 
 them together. Impulsiveness is sufficiently charac- 
 terised by its title. It is a sudden, unexpected outbreak 
 of riotous activity. It is never manifested except by 
 those who are already suffering from some other form 
 of insanity, or who are epileptic. It is most frequently 
 associated with epilepsy, with acute insanity, and with 
 stupor ; but sometimes is seen in dementia, especially 
 in the young, and in melancholia. The patient, who 
 may have been for hours, days, or even weeks, in a 
 state of calm, or even of stupor, with great defect of 
 activity, suddenly and without warning breaks out 
 into extreme violence, which is usually of frantic and 
 unintelligent character. He rushes to the window 
 and jumps through it, but so undirected and unintelli- 
 gent is his action, that not only is he indifferent as 
 to whether it is open or shut, but he will thrust 
 arms and legs through different panes of glass, thus 
 effectually barring his purpose, if he had a purpose, 
 of getting to the other side. Or he suddenly seizes 
 the tablecloth, and with one frantic jerk sweeps all 
 the breakfast things on to the floor ; or he seizes a 
 weapon and attacks indiscriminately everybody within 
 his reach ; or he directs his violence against inanimate 
 objects, smashing windows, mirrors, ornaments, and 
 everything breakable to which he has access ; or he 
 seizes a knife and cuts his own throat or arm, or 
 stabs a bystander. Whatever the precise nature of 
 the act, it is characterised by its suddenness, by its 
 apparent want of motive or provccation, and by 
 its want of intelligent direction. 
 
 Obsession is allied to impulsiveness in its motor 
 character. It is a prompting to action, and the action 
 10 which it prompts is often, even usually, sudden in 
 its occurrence ; but it differs from impulsive action 
 
94 TEXT-BOOK OF INSANITY. 
 
 in being preceded by a period of hesitation and 
 struggle, prolonged, it may be for hours, it may be 
 for months or years. The commonest and most 
 innoxious form of obsession is the prompting to 
 vocal utterance that we have when an air of music, 
 a line of poetry, a proverb, or some other verbal or 
 vocal sound presents itself again and again, becomes 
 more and more prominent in the mind, until at last 
 it gets itself uttered aloud. Another variety, less 
 frequent, but not infrequent, is the absurd anxiety 
 that we sometimes have, when walking on a flagged 
 pavement, to avoid treading, or to insist upon treading 
 on the intersections of the stones. Another not 
 infrequent variety is the touching of posts, and other 
 regularly occurring objects. Closely allied to touching 
 of recurring things is the counting of them, and many 
 people count things as they pass in carriages or trains 
 windows, houses, telegraph poles, bridges, bicyclists, 
 or what not until they are weary and annoyed with 
 themselves for their waste of time and energy. In 
 all such normal or quasi-normal case?, the practice is 
 easily relinquished, and the action which is prompted 
 is itself innocent. The morbid varieties of obsession 
 are distinguished by excess in both directions. The 
 action which is prompted may indeed be innocent, 
 and often, in fact, is the counting that we have 
 already described ; but often it is a criminal or vicious 
 act ; and, in any case, the prompting is persistent and 
 prolonged and repeated, and cannot be dismissed at 
 will, but maintains its force and vividness, in spite 
 of every struggle to subdue it. Thus, a person is 
 compelled to count, say to ten, before anything that 
 she wishes to do can be done. When she rises in the 
 morning, she must count ten before she can wash 
 
FORMS OF INSANITY OBSESSION. 95 
 
 herself; ten before each article of clothing can be 
 put on ; ten before she can open the door ; ten, 
 perhaps, on each stair, before she can descend to the 
 next ; and so throughout the day. Or it may still 
 be an articulatory utterance, but of an objectionable 
 character. The words that present themselves and 
 demand utterance may be obscene or blasphemous, 
 and may present themselves with such vividness and 
 persistence and constancy of repetition that at last 
 they become uttered aloud, to the pain and grief and 
 horror of the utterer. Again, in some cases the act 
 prompted may be suicidal or homicidal, and may recur 
 with increasing persistence and force until at length 
 the sufferer seeks police protection against himself, 
 or implores the shelter of a lunatic asylum to preserve 
 himself from crime, which he abhors, but which he 
 feels that he cannot but commit. 
 
 In all these cases there is a strenuous and prolonged 
 struggle within the patient's mind, between the im- 
 pulsion to the deed and the determination to resist 
 and abjure it, so that his life is one long internal 
 strife and hesitation. In yet another class of cases, 
 a similar balance of motives exists, a similar pro- 
 longation of hesitation takes place, over all the simple 
 and harmless acts of daily life. The period of delay 
 and hesitation is not, as in the case previously men- 
 tioned, rilled up by counting, but is a simple conflict 
 of motives as to whether, for instance, the right boot 
 or the left should be put on first, or whether there 
 may not be sin in eating a piece of bread and butter, 
 and so forth. This variety of obsession is called 
 folie du doute, or doubting mania. 
 
96 TEXT-ROOK OF INSANITY. 
 
 K. MORAL PERVERSION. 
 
 The fabric of morality rests upon a single foundation, 
 viz., the ability to forgo a pleasure or incur a pain, 
 now, upon the instant, in order that by our present 
 self-denial we may secure benefit hereafter. Lack 
 of this ability is evinced in vice, by which is meant 
 immediate indulgence at the cost of disproportionate 
 detriment hereafter. When vice is pushed to excess, 
 it becomes insanity ; and there are certain forms of 
 insanity that are characterised, if not entirely, yet 
 mainly and most conspicuously, by the excess of 
 vice as here defined. Every form of self-indulgence, 
 when it entails no subsequent detriment, either to 
 the actor or to others, is right and proper and moral. 
 Only when it involves subsequent detriment to the 
 actor is it vicious, and the degree of vice is marked, 
 not only by the magnitude of the difference between 
 the present pleasure and the future pain, but also 
 by the certainty with which the pain is incurred, 
 and by its imminence at the time the pleasure is 
 indulged in ; and when, in any of these respects, the 
 degree of vice becomes extreme, it amounts to insanity. 
 The thief who knows that his theft will never be 
 discovered is not vicious in the sense in which " vice " 
 is used here. If his booty is of great value and he 
 knows that his punishment will be light and will not 
 involve its restitution, he is still not vicious, for the 
 benefit that he gets outweighs the pain that he 
 incurs. If he incurs a heavy penalty, but there is 
 little chance of his conviction, and of the penalty 
 being inflicted, still he is not vicious ; and if the 
 penalty is both heavy and certain, but will be long 
 delayed, then whatever the turpitude of his act, it 
 
FORMS OF INSANITY-MORAL PERVERSION. 97 
 
 is but little vicious in this sense of the word " vice." 
 But if the opposite state of things obtains, then the 
 vice becomes extreme, and extreme vice is insanity. 
 The man who steals under the very eye of the owner 
 of the property, with the policeman standing by ; the 
 boy who takes the tarts while the pastrycook stands 
 over him with uplifted cane ; the clerk who embezzles 
 money the day before the audit, well knowing that 
 his defalcation must be discovered on the morrow ; 
 the candidate for a place who goes drunk to his would- 
 be employer; exhibit a degree of vice so great as to 
 border upon insanity, and beyond such a degree as 
 this the insanity becomes unquestionable. There 
 are persons who indulge in vices with such persistence, 
 at the cost of punishment so heavy, so certain, and 
 so prompt, who incur this punishment for the sake 
 of pleasure so trifling and so transient, that they are 
 by common consent considered insane, although they 
 exhibit no other indication of insanity. 
 
 The following cases are illustrative of moral insanity : 
 An Afghan who had been deprived first of his right hand 
 and then of his left, struck off in punishment for theft, 
 seized with his stumps, and made off with, an earthen- 
 ware pot of very trifling value, and did this under 
 the very eyes of the police, well knowing that he 
 would probably be hanged next morning, as in fact 
 he was. A lad at college, the son of well-to-do parents, 
 who kept him well supplied with clothes, and made 
 him an ample allowance, stole a suit of clothes and 
 a pair of boots from a fellow-student. He was seen 
 to come away from his fellow-student's room with the 
 clothes under his arm, but though he lied elaborately 
 when taxed with the theft, he made no effort to 
 conceal the stolen things, but left them lying about 
 
 7 
 
98 TEXT-BOOK OF INSANITY. 
 
 his room. He was expelled and sent home, and a 
 few days afterwards he went to his father's bedroom, 
 packed up his father's shirts, brushes, razors, etc., in 
 a gladstone bag, and sold the lot to a man in the 
 street for five shillings. A man of good social position 
 and respectable ability, the colonel commanding a 
 crack regiment, frequented low pot-houses, where he 
 boozed with private soldiers of the lowest class, gave 
 away his watch and chain and jewellery, and became 
 filthy in person and swarming with vermin. A private 
 soldier, on being reprimanded on parade by a 
 commissioned officer for some trifling untidiness, 
 smacked this officer in the face, and even when in 
 prison, could not be got to see the matter in any 
 other light than that of a good joke. These are cases 
 of true " moral insanity," but what are we to say of 
 the frequent cases in which women of ample means 
 and good social position steal from drapers' shops ? A 
 small proportion of these are no doubt cases of moral 
 insanity, but the majority of them are ordinary 
 thieves, who presume upon their social standing and 
 respectability to avert suspicion in the first place, 
 and in the second to carry them scatheless if they 
 happen to be discovered. Such women are not usually 
 discovered to be thieves until they have continued 
 the practice for some time and become bold from 
 immunity. They execute their thefts with cunning 
 and elaborate precautions, and when discovered they 
 plead " kleptomania," which, in such cases, means 
 theft by the well-to-do. 
 
 The consideration of moral perversion would not 
 be complete without mention of the subject of 
 perversion of the sexual instinct, about which such 
 a redundant amount of literature has lately been 
 
FORMS OF INSANITY MORAL PERVERSION. 99 
 
 produced. There is no doubt that there are abnormal 
 beings of both sexes whose sexual inclinations are 
 towards members, not of the opposite, but of their own 
 sex, and these inclinations they gratify by various 
 disgusting quasi-sexual proceedings. The fact being 
 recognised, all has been said that need be said. 
 
CHAPTER VII. 
 
 VARIETIES OF INSANITY. 
 
 1. IDIOCY AND IMBECILITY. 
 
 THESE defects are distinct clinically, legally, and, 
 to a certain extent, etiologically also, from other forms 
 of insanity. They are universally regarded as different 
 degrees of the same defect, but no dividing line is 
 commonly drawn between them. As it is convenient 
 that distinct names should denote distinct tilings, 
 I am in the habit of limiting the term " idiot " to 
 those persons who are unable to acquire even the 
 simple modes of conduct of the directly self-conserva- 
 tive class, and who require constant supervision and 
 care to preserve them in safety ; while by " imbeciles " 
 I understand those who have fully acquired the 
 activities of this class, and can be trusted to go 
 about by themselves and to avoid the common dangers 
 of the house and the streets, but whose intelligence is 
 so defective that they are unable to acquire the in- 
 directly self-conservative activities that is to say, 
 their industry, and they are often industrious, is not 
 intelligent enough to give it a sufficient market value 
 to enable them to maintain themselves. The dis- 
 tinction is clear, and it is practically convenient, 
 
 since it enables us to distinguish the imbecile, not 
 
 100 
 
IDIOCY AND IMBECILITY. 101 
 
 only from the idiot at one end of the scale, but from 
 the normal stupid person at the other. However 
 stupid a man may be, we do not call him imbecile 
 unless his intelligence is so defective that by reason 
 of his defect he is unable to maintain himself ; and 
 when this degree of defect is reached, we have no 
 hesitation in applying to him this title. 
 
 Idiots and imbeciles are alike in this : that their 
 defect is congenital, or at least original that is to 
 say, they have not lost their intelligence, they have 
 never attained it. They are not dements, but aments. 
 In them the highest regions of the brain have never 
 attained to the normal standard of the race; their 
 development has come to a premature close. The 
 highest region of the brain is the very last to attain 
 completeness, and when the process of development 
 ceases prematurely, it is this region which remains 
 most defective. There are two ways in which the 
 premature cessation of development may occur. The 
 process may run down from insufficiency of the impetus 
 which set it going, as a bullet may fall short of the 
 target for want of a sufficient charge of powder behind 
 it ; or it may have started on its career with a normal 
 and sufficient vigour, and have been brought to a 
 premature close by some extrinsic agent by disease 
 or accident affecting the brain. 
 
 The developmental impetus which the germ receives 
 at conception may be insufficient in very various extent. 
 It may apparently be so extremely deficient that the 
 foetus perishes in utero ; or the child may come to the 
 birth, and may linger a few days or weeks, and die 
 at length from no definite malady, but from mere 
 insufficiency of " vital power," or " nervous energy.'' 
 Instead of being wound up to go eighty years, the 
 
102 TEXT-BOOK OF INSANITY. 
 
 clock runs down in a few days from mere weakness 
 of the spring. Supposing, however, that there is 
 enough of inherent energy to keep the machine going 
 for a few years, there may yet not be enough to carry 
 on the process of development to its normal con- 
 clusion. The whole of what energy there is is 
 exhausted in the effort to keep life going, and none 
 is left available for the increase of life. Idiots of this 
 origin " developmental idiots " or " genetous idiots," as 
 they are called give evidence of their defect in other 
 ways. They are always short-lived. P'or the contest 
 between integration and disintegration, of which every 
 life consists a contest in which integration at first 
 predominates, at first with increasing and then with 
 slackening vigour, then for a long while maintains an 
 equal footing, and at length yields with ever diminish- 
 ing vigour to disintegration the idiot is so inade- 
 quately equipped that the turning point occurs long 
 before his full equipment is attained. The taper of 
 his life burns so feebly that it is only by sedulous 
 care that it can be maintained even for a few years ; 
 and before he reaches his teens, some of the many 
 maladies, which healthy children live through without 
 difficulty and without detriment, extinguish his little 
 flame. The idiot never develops more intelligence 
 than is possessed by the normal infant. Even at ten 
 or twelve years, if he live so long, he may not be 
 left alone without immediate danger to his life. Even 
 physically, it is long before he emerges from babyhood. 
 He lies helpless in his cradle for years after other 
 children of his age are running about and at boisterous 
 play. In many cases he never attains, in no case does 
 he attain until several years old, the command over his 
 sphincters and the intelligence to pass his excrements 
 
IDIOCY AND IMBECILITY. 103 
 
 appropriately ; and the ability to prehend his food 
 and carry it to his mouth is similarly delayed or 
 similarly unattained. 
 
 The immediate cause, or rather the essential nature, 
 of idiocy is in every case the non-attainment of com- 
 plete development of the brain ; but the conditions 
 of this non-development are various. The brain may 
 fail to develop from sheer defect in the developmental 
 impetus, by reason of which the process ceases prema- 
 turely of its own accord, or it may be cut short by 
 interference from without. 
 
 Among the reasons of premature spontaneous cessa- 
 tion of development a few have been assigned with 
 some degree of probability. Of these, senility of 
 either parent seems to be one. The last pregnancy, 
 when the mother is on the verge of the climacteric 
 change, often results in an abortion, often in a child 
 which dies after a few days or weeks of birth, and 
 sometimes in a child which lives longer and proves to 
 be an idiot. If the father is of advanced age when 
 the child is conceived, the child is sometimes idiotic. 
 There seems some reason to suppose that great intem- 
 perance on the part of either parent may be a cause 
 of idiocy in the offspring, but looking to the great 
 number of drunken parents whose offspring are healthy, 
 the influence of drunkenness can be only contributory 
 or corroboratory of some other cause. Idiocy some- 
 times occurs in children who are born prematurely, 
 and in such a case the mode of causation is tolerably 
 obvious. 
 
 In the majority of cases, development does not expire 
 from mere want of impetus, but is cut short prema- 
 turely by some interference of a quasi-accidental 
 nature. Among these a prominent place is taken 
 
104 TEXT-BOOK OF INSANITY. 
 
 by trauma. Prolonged parturition, with the pressure 
 on the yielding bones of the head that it involves, 
 sometimes produces such structural damage to the 
 brain that it never recovers ; and instrumental delivery 
 undoubtedly produces local injury in some cases, re- 
 sulting in non-development of the motor area on one 
 side, and consequent paralysis, with imperfect develop- 
 ment of the limbs, upon the opposite side. Cases of 
 congenital hemiplegia, with stunted growth of the 
 affected limbs, paresis, and very often with choreiform 
 movements of the affected side, spreading, it may 
 be, to the rest of the body, are very common, and 
 are always associated with corresponding imperfection 
 in intelligence, amounting to imbecility and some- 
 times to idiocy. Some of these cases can be 
 assigned with certainty to injury to the head during 
 birth, while in others the non-development of the 
 convolutions seems to be due to arterial obstruction 
 in early life. 
 
 The condition just described is frequently associated 
 with epilepsy, and often epilepsy without such gross 
 structural damage begins in early life, and is then 
 associated with mental defect. It is common to speak 
 of the idiocy or imbecility associated with epilepsy 
 as epileptic, and if all that is meant is a convenient 
 clinical description, the term may be allowed; but if 
 by " epileptic idiocy " be meant idiocy dependent on 
 epilepsy as a cause, the appellation is unwarranted, 
 for we do not know whether the mental defect is due 
 to the epilepsy or whether, as seems much more likely, 
 both are manifestations of the same organic defect in 
 the brain. 
 
 Damage may be done to the brain, and its develop- 
 ment arrested, by poisonous matters assimilated by 
 
IDIOCY AND IMBECILITY. 105 
 
 it from the blood in the process of nutrition. To this 
 we attribute the rare instances of imbecility in which 
 the stigmata of hereditary syphilis are recognisable, 
 and in part also, the less rare cases in which the 
 development of the brain ceases, or proceeds but 
 imperfectly, after an attack of specific fever in early 
 youth whooping cough, measles, scarlet fever, or, less 
 frequently, typhoid. It is to be borne in mind, 
 however, that these maladies are liable to be com- 
 plicated by meningitis, and therefore may arrest the 
 central development in another way. 
 
 Allied to the last group are cases in which develop- 
 ment of the brain fails for lack of some indispensable 
 constituent in the pabulum supplied to it. This is 
 unquestionably the case in cretinism, in which the 
 brain partakes in the general defect of the development 
 of the whole body, owing to the lack of the essential 
 product of the thyroid gland. There is another form 
 of idiocy in which non-development or mal-development 
 of the whole body in a constant co-ordinated manner 
 leads us to suspect that the lack of some essential 
 nutritive constituent is at the root of the defect. 
 This is what is known as microcephalic idiocy. In 
 microcephaly the head is amazingly small, but this 
 is far from being the only anomaly, and the associated 
 anomalies are constant, as in cretinism. There is a 
 family likeness among all such cases ; they are so 
 much alike in features and disposition that they might 
 all be brothers and sisters to each other. The hair 
 is unusually coarse and thick, the face is large, not 
 only in proportion to the cranium, but to the rest of 
 the body, the stature is diminutive, the nose is 
 aquiline, the eyes are inclined to be large ; they differ 
 from all other idiots in their liveliness and rapidity 
 
106 TEXT-BOOK OF INSANITY. 
 
 of movement, they are highly imitative, and are 
 often passionate. 
 
 It is probable that to a similar influence is owing 
 the Mongolian type of idiot, so described by Dr. 
 Langdon Down, in which there is exhibited a co- 
 ordinated system of characters in constant association. 
 The small, obliquely placed, widely separated palpubral 
 fissures, the rounded ears, the depressed nose, the 
 large and fissured tongue, the stumpy fingers, the 
 imitativeness and the teachability, form a well-marked 
 group of characters which always go together, and 
 which we are therefore warranted in supposing to be 
 due to a common cause. 
 
 Among the common forms of gross damage to the 
 brain in early life is hydrocephalus, which, when 
 sufficient in degree to be recognisable that is to say, 
 to cause obvious enlargment of the cranium of necessity 
 gives rise to mental defect, varying from imbecility 
 down to the deepest idiocy. Hydrocephalics are not 
 long-lived, but pretty often live to adult age. 
 
 The mental defect that sometimes occurs in the 
 deaf and dumb is usually included among the forms 
 of idiocy under the title of " idiocy from privation," but 
 it is obvious that it is wrongly so styled, for the great 
 majority of the deaf and dumb are, if not of normal 
 intelligence, at any rate able to maintain themselves 
 by their own labour, and are therefore not only 
 themselves excluded from the class of imbeciles, but 
 prove beyond question that the defect from which 
 other deaf-mutes suffer is not due to the privation of 
 hearing and speech. In them there is probably some 
 cerebral defect which underlies at once the deaf- 
 mutism and the imbecility. 
 
VARIETIES OF INSANITY DEMENTIA. 107 
 
 2. DEMENTIA. 
 
 Clinically the term " dementia" is used to characterise 
 the very large group of cases in which diminution of 
 intelligence constitutes the most conspicuous feature 
 in the malady. It is distinguished from idiocy and 
 imbecility by its history, for whereas in these a 
 normal grade of intelligence has never been attained, 
 in dementia the individual is degraded. A normal 
 grade of intelligence, once attained, has been lost. 
 The one has never risen above the rank of the pauper ; 
 the other has once been affluent, but is reduced to 
 poverty. Apart from the history, there is little to 
 distinguish them except the age of the patient, and 
 this is by no means a sure criterion. Idiots, it is true, 
 rarely attain adult age ; and a person who is mentally 
 deficient in early life, before the development of 
 intelligence is complete, is not a dement. But many 
 imbeciles live to middle life and old age, and are then 
 indistinguishable mentally from dements ; and many 
 young adults become demented and might be taken 
 for imbeciles but for their history. Both imbeciles and 
 dements are liable to outbreaks of excitement, in which 
 the form of their insanity becomes that of mania 
 for the time being. Many patients who, from their 
 quietude and absence of conspicuously active insanity, 
 would be classified clinically as dements, are found, 
 upon examination, to hold delusions of more or less 
 fixed type, and thus might, with equal propriety, be 
 placed in another class. By " dements " as a variety 
 of insanity we mean those insane persons in whom 
 simple impairment of sanity is the most conspicuous 
 feature, whose intelligence, feeling, and conduct are on 
 the whole much diminished, but who may entertain 
 
108 TEXT-BOOK OF INSANITY. 
 
 delusion, who may from time to time exhibit outbreaks of 
 excitement or of perversion of mind and conduct, who 
 may now and then become exalted or depressed. When 
 they exhibit these additional symptoms, the form of 
 the insanity is no longer pure dementia, but still 
 they would be clinically classed among dements, the 
 dementia being still the most conspicuous feature of 
 their condition. 
 
 As a clinical entity, dementia is the natural termina- 
 tion of life. In the vast majority of cases life is cut 
 short by accident, or by the quasi-accident of bodily 
 disease ; but when it goes on until it ceases from pure 
 exhaustion of the quantum of energy that it received 
 at conception, it has to pass through dementia on its 
 way to the end. Some degree of dementia, some 
 diminution of the vividness of feeling, of the capacity 
 of thought, of the range and variety of conduct, is 
 the natural and inevitable accompaniment of the decay 
 of the bodily power in old age ; and it often happens 
 that the decay of the highest regions of the brain 
 outstrips that of the body, so that the dementia sets 
 in earlier, is more pronounced in degree, and is more 
 irregular in its manifestations than is usual and normal 
 in old age, and is out of proportion to the decay of 
 the bodily capacity. The condition then presented 
 is the clinical condition of senile dementia. 
 
 In senile dementia the most conspicuous aspect is 
 defect of memory ; the most conspicuous fault is the 
 outbreak of ill-temper. The defect of memory is 
 peculiar, and is characterised by the evanescence of 
 the memory of passing experiences while the memories 
 of long-past experiences are not only retained, but are 
 increased in their prominence, in their intensity, and 
 in the frequence with which they are present in con- 
 
VARIETIES OF INSANITY DEMENTIA. 109 
 
 sciousness. The first approaches of senility, which are 
 perceptible between forty and fifty, are marked, as has 
 been said, by an inability to recall newly acquired 
 names, whether of persons or of things, and generally 
 by a want of nimbleness in the use of substantives- 
 As age advances, experiences produce impressions 
 that are less and less enduring, and, in the dementia 
 of old age, become so transient that events are not 
 remembered from hour to hour, and often not from 
 minute to minute. A senile dement will declare that 
 he has not seen for months a person who spoke to him, 
 and whom he recognised and answered, five minutes 
 before he makes the declaration ; and no matter how 
 important or impressive the event, its memory is 
 equally evanescent. While he thus forgets with 
 abnormal celerity and completeness current events, 
 he retains with punctual fidelity the memories of 
 experiences that he underwent in youth, and is able 
 to give accurate descriptions of events that happened 
 fifty or sixty or more years ago. Nor is this all ; the 
 memories of long-past experiences are not only faithful, 
 often surprisingly and unusually faithful and detailed, 
 but they thrust themselves forward and occupy a much 
 larger share of consciousness than is usual. People in 
 middle life, and normal people in old age, are occupied 
 mainly with the current experiences of their daily life ; 
 and the reminiscences of childhood are before the mind 
 but seldom, and for short periods. But in many cases 
 the senile dement lives his childhood over again. He 
 is perpetually maundering about things that happened 
 before his hearers were born, about the events of his 
 school life and his early love affairs, and not very 
 infrequently these memories of bygone experiences 
 take such hold upon him that he actually mistakes 
 
110 TEXT-BOOK OF INSANITY. 
 
 the people about him for the companions of his early 
 life. He addresses his grandchildren by the names of 
 his schoolfellows, and takes his daughter for his first 
 sweetheart . 
 
 Together with this peculiar defect of memory there 
 is usually in senile dementia an irritability of temper, 
 a petulance and impatience, which reproduce the 
 peculiarities of a spoilt child. If they want a thing, 
 they must have it on the instant ; they cannot wait 
 until it is prepared or until it is fetched ; they must 
 have it now, this moment ; and if it is not forthcoming 
 they fly into a rage, they stamp, they shout, they 
 swear, and they often offer such feeble violence as 
 they are capable of. Like the child, too, they are 
 easily coaxed into a good humour again ; their ill- 
 temper is transient, and its occasion soon forgotten. 
 Another characteristic is the wearisome iteration with 
 which they will repeat the same thing, their defect 
 of memory rendering them oblivious to the frequency 
 of the repetition. Indeed, the repetition of the same 
 story at short intervals to the same person is as 
 common an indication of the advent of senility as is 
 the difficulty of dealing with substantives that has 
 already been mentioned. 
 
 As in idiocy, so in dementia, the failure of sanity 
 may be due to premature exhaustion of the develop- 
 mental impetus, or it may be due to the interference 
 of some extrinsic cause which does not allow the 
 structure to crumble down, but violently pulls it down. 
 To enumerate the causes of dementia would be to 
 enumerate those of insanity, for every other form of 
 insanity is dementia with superadded symptoms. In 
 acute insanity, the superadded activity is so over- 
 whelmingly important and predominant that the 
 
VARIETIES OF INSANITY DEMENTIA. Ill 
 
 dementia which underlies it attracts no attention. 
 When the active symptoms subside, they leave the 
 dementia outstanding ; and thus it is usually said that 
 dementia is a result of a previous attack of insanity ; 
 and while this is a convenient way of describing the 
 sequence of clinical events, yet, if we are to be 
 scientifically correct, we ought to say that the sub- 
 sidence of the active symptoms reveals the dementia 
 which has throughout co-existed with them. Clinically, 
 we call a case of insanity one of dementia, not only 
 when the active symptoms are absent, but when they 
 are but little prominent, or when they are occasional 
 only. Dementia is, in fact, the common form of all 
 insanity, but, when other symptoms are added to the 
 defect of conduct, intelligence, and feeling which 
 constitute pure dementia, we give to the form of 
 insanity some other name, if these symptoms are 
 conspicuous or enduring. If they are not prominent, 
 or only occasional, we still call it dementia. Insanity 
 may come on in middle or early life, may run its 
 course, and may slowly increase for years, until it 
 reaches a great depth of dementia, without at any time 
 exhibiting any of the active symptoms which would 
 enable us to class it as mania or melancholia, and 
 without ever being accompanied by delusion, at any 
 rate by prominent delusion ; and such a case would be 
 called one of primary dementia. 
 
 Usually, however, the onset of the insanity is 
 attended by active symptoms, according to which 
 the insanity receives its title, and only after it 
 is laid bare by their subsidence does the dementia 
 come into clear view. Hence the great majority 
 of cases of dementia are called secondary, and 
 are looked upon as consequences of previous attacks 
 
112 TEXT-BOOK OF INSANITY. 
 
 of more active insanity. But in every case of 
 insanity the essential feature is defect. In no case 
 does disease make a real, a fruitful, addition to function. 
 The affection of function is always in the direction of 
 loss, of defect, of diminution. In inflammation, tissue 
 change is increased in activity, it is true, but it is 
 carried on upon a lower level. There is increase of 
 process, but there is diminution of function. In 
 glycosuria there may be increased production of sugar 
 by the liver, but there is no real elevation of the 
 function of this organ, and the general functions of the 
 body are not increased, but diminished. And so it is in 
 active insanity. In mania there is great increase of 
 activity ; in melancholia and in exaltation there is great 
 increase of feeling; in delusion there is increase in 
 the ability of mental states to enter into coherent 
 combinations. But none of these states of increased 
 activity indicate real operative increase or elevation of 
 function. On the contrary, they are accompanied by, 
 and they indicate, diminution of function. For with 
 all the vivacity of thought that obtains in mania, there 
 is always an inability to appreciate the circumstances 
 in which the individual is, and his true relations to 
 these circumstances. With all the increased activity 
 of conduct, the conduct is on a lower level ; it is not, 
 and cannot be, adapted to the circumstances, for the 
 power of adapting conduct to circumstances, the 
 highest function of the brain, is defective. With all 
 the increased intensity of feeling, with the depression 
 or the exaltation, there is still the mal-adjustment of 
 this feeling to the circumstances, and there is still the 
 inability to bring the feeling into correspondence with 
 the circumstances. And the important, the vital 
 disorder, is not so much the increase of activity, as the 
 
VARIETIES OF INSANITY DEMENTIA. 113 
 
 degradation of activity to a lower level ; is not so much 
 the excess as the defect ; is not so much the mania, or 
 the melancholia, or the exaltation, or the delusion, 
 as the inability to appreciate the mal-adjustment of 
 conduct and thought and feeling to circumstances, and 
 to bring about readjustment. So that, in all cases 
 of insanity, the real and important aberration is not 
 necessarily the most conspicuous feature the over- 
 action which may be regarded as adventitious, and to 
 a certain degree as accidental, but the degradation of 
 activity to a lower plane ; and it is this degradation 
 that is indicated by the term " dementia." 
 
 Allowing that in all forms of insanity this degra- 
 dation of conduct exists, then the clinical kind of 
 insanity will depend upon whether the defect is 
 simple that is to say, upon whether the activity 
 of mind and conduct are merely degraded and 
 diminished, and upon the lower plane to which 
 they are reduced no excess of activity takes 
 place, in which case it is simple dementia ; or upon 
 the kind and degree of inferior and debased activity 
 that goes on at this lower level. When the debased 
 activity is marked by excess of feeling, we call it 
 melancholia or exaltation, as the case may be ; when 
 it is exhibited in excess of low-grade conduct, we call 
 it mania ; when it occurs in the formation of beliefs, 
 we call it delusional insanity. In any case of simple 
 dementia, over-action may occur at the low level to 
 which the nervous organisation is reduced, and then we 
 call it a case of dementia with outbreaks of excitement, 
 or of dementia with delusions, and so forth. Even 
 when the dementia is deep, when the level to which 
 the nervous organisation has been degraded is very low, 
 some over-action upon this lower plane is usual, and 
 
 8 
 
114 TKXT-BOOK OF INSANITY. 
 
 then we witness those forms of dementia in which the 
 jiatient is excessively voracious, in which he eats all 
 kinds of filth and rubbish without distinction ; in which 
 he collects stones and sticks and bits of string and 
 other rubbish ; in which he tears and destroys his 
 clothing and anything he can get hold of; in which he 
 exhibits for many hours every day, and every day for 
 years together, some simple and inappropriate form of 
 conduct ; in which he shouts and screams, or pats his 
 leg, or rubs his clothes together as if in the washtub, 
 or rocks himself backwards and forwards in his chair, or 
 repeats the same form of words. 
 
 The degrees of dementia are practically infinite. 
 They range from the trifling decadence of intelligence, 
 feeling, and conduct that is exhibited by any one after 
 an enfeebling illness, or at the end of a tiring day, 
 down to the almost total obliteration of consciousness 
 and movement in the latest stage of such a disease as 
 general paralysis, in which the patient lies a mere log, 
 insensible to all that is passing around him, passing 
 his motions and urine as he lies, allowing the flies to 
 walk over his face and into his open mouth without 
 showing the least sign of disturbance, indifferent to 
 the sight and smell of food when placed before him, 
 incompetent even to chew the food placed in his 
 mouth, and exhibiting only sufficient intelligence to 
 swallow the pulp with which he is fed. 
 
 In this long and uniformly diminishing series we 
 may mark off separate grades where we please, and 
 whatever divisions we make will be wholly artificial ; 
 but there is a practical convenience in distinguishing 
 between grades of dementia, and the first grade that we 
 may distinguish is that in which the social activities 
 alone, or chiefly, are defective. In this respect all the 
 
VARIETIES OF INSANITY-DEMENTIA. 115 
 
 insane, without exception, are deficient. As the higher 
 social qualities are the last to be acquired, so they are 
 the first to be lost when complete sanity begins to fail. 
 We never find an insane person who is quite polite. 
 Ceremonious they often are in an exaggerated degree, 
 but polite, in the sense of exhibiting those little 
 benevolences which are as oil in the running of the 
 social machine, they never are. Even the sanest of the 
 insane are deficient in courtesy. They may bow you 
 into their room with an exaggerated affectation of 
 ceremony, but they fail to offer you a chair; or, if 
 they go as far as this, they exhibit their want of civility 
 by engrossing the conversation, and in talking exclu- 
 sively about themselves ; in their naive boastfulness ; 
 their engrossment in their own affairs ; their indiffer- 
 ence to the little ordinary duties of hospitality ; in the 
 absence of all effort to entertain. In the next grade 
 of dementia the indifference to social obligations is 
 greater. The subject of it will receive you in his 
 shirt-sleeves, he will go about the streets in his 
 dressing-gown and slippers, he will go to a funeral in 
 a shooting suit. If a woman, she will be indifferent to 
 her personal appearance, be untidy, slovenly, and dirty 
 in her dress, will go about with tangled hair, loose 
 stockings, and shoes down at heel. If a man, he swears 
 freely before ladies and strangers, and introduces 
 objectionable topics of conversation without discerning 
 any impropriety in so doing ; or he may go further, 
 and introduce loose women, perhaps his own mistress, 
 to his wife and daughters, and even bring her to live 
 in the same house, oblivious to the objectionable 
 character of his conduct. He loses reticence, and 
 speaks familiarly of his family affairs, of his income, of 
 his differences with his wife, of his son's misconduct, 
 
116 TEXT-BOOK OF INSANITY. 
 
 and his daughter's epilepsy, before strangers, in railway 
 carriages, in hotel smoking-rooms, in his club. If a 
 woman, she will talk with similar want of reticence of 
 her confinements and miscarriages, of her husband's 
 unfaithfulness, or her own amours. 
 
 The grades of dementia described above may co-exist 
 with full ability to earn the livelihood and administer 
 the means, but in the next grade these modes of 
 conduct also are affected, and the patient becomes 
 either incapable of appreciating the importance of 
 continuing his regular employment and of regulating 
 his expenditure according to his income ; or, while 
 recognising the importance of doing so, incapable of 
 appreciating what his income is, and therefore what 
 his expenditure should be ; or deficient in ability to 
 follow his employment. In conjunction with these 
 defects we meet with many forms of excessive action 
 upon a lower level, which will be alluded to in other 
 connections. 
 
 The lowest grade of dementia is exhibited by those 
 who have not only wholly lost their ability to ad- 
 minister their means, but who are deficient also in 
 that primitive group of activities by which existence 
 is preserved from day to day and from hour to hour. 
 If their food is not brought to them, they will make 
 no effort to provide it for themselves. They have 
 not sense enough to come in out of the rain. If the 
 house were on fire they would not know which way to 
 go to get out of it, even if it occurred to them that 
 it was desirable to escape. Conduct is reduced to 
 finding the way from the bedroom to the sitting- 
 room, from the fireside to the meal-table, and back 
 again ; or even this modicum of intelligence is lost. 
 Even in this lowest grade of dementia degrees or 
 
VARIETIES OF INSANITY DEMENTIA. 117 
 
 sub-grades are apparent. The most intelligent of 
 these dements are clean in their personal habits. 
 The next lower grade is when they pass their urine 
 under them, but go to the closet to defsecate. Then 
 this is lost also, and their motions are passed in their 
 clothes. Then they become incapable of dressing 
 and then of undressing themselves; and the last 
 acquirement to be lost is the art of carrying the 
 food to the mouth when it is placed before them. 
 Even in this accomplishment there are degrees, for 
 some can use a knife and fork, some a spoon only, 
 and last of all, this implement is abandoned, and the 
 fact that fingers were made before spoons is practically 
 exemplified, since their use is retained longer. 
 
 Several clinical varieties of dementia are commonly 
 enumerated, but how far it is correct to describe them 
 as distinct is doubtful. The primary, the secondary, 
 and the senile are separately dealt with. In addition 
 to these, there has been described an alcoholic 
 dementia, which will be dealt with among the in- 
 sanities due to alcohol, and general paralysis is 
 sometimes termed by Continental writers dementia 
 paralytica. The only form of dementia which has 
 a true clinical distinctness and constitutes a separate 
 clinical entity is that which is known as stupor. 
 
 3. STUPOR. 
 
 This is as nearly a distinct and separate form, as 
 well as variety, of insanity as there is. In pronounced 
 cases it is quite unmistakable, but it is not always 
 pronounced, and an element of stupor may often be 
 distinguished in cases of dementia that would not 
 be called stuporous, and especially in the young, for 
 
118 TEXT-BOOK OF INSANITY. 
 
 stupor occurs usually, though not exclusively, in early 
 life. It exhibits the signs of exhaustion of nervous 
 energy, as though the highest regions of the brain 
 had been emptied of motion and had ceased to act ; 
 and it is usually preceded by experiences which are 
 calculated to drain these regions of their energy, 
 and especially by a combination of several such 
 drains. If we wished to produce a case of stupor, 
 we should take a young man between the ages of 
 eighteen and twenty-five, subject him to severe and 
 exhausting bodily fatigue, let him at the same time 
 work hard in preparing for an examination, let him 
 work too many hours a day, and have insufficient 
 food, and especially insufficient sleep; and above all, 
 let him masturbate freely, and at the end of a month 
 or two he will become insane, and his insanity will 
 take the form of stupor. If he is so exceptionally 
 strong that these measures fail to break him down, 
 the last effort of resistance can be overcome by sub- 
 jecting him to some severe shock. Let him be 
 involved in a railway or other accident, or let him 
 even witness one, or let him come suddenly upon 
 a dead body, or see his schoolfellow dragged drowned 
 out of a river, or let him be assaulted and robbed, 
 or set his house on fire in the night. By such 
 means may stupor be infallibly produced even in 
 a strong nature; and a weak nature will not require 
 such an aggregation of causes. Any one of them will 
 suffice sometimes, any two of them or three of them 
 will usually suffice, especially if excessive masturbation 
 be among them, though this last factor is by no means 
 essential to the causation of stupor. 
 
 Whatever the causation, the insanity may be 
 stuporose from the outset ; but more usually to the 
 
VARIETIES OF INSANITY STUPOR. 119 
 
 exhausting conditions that have been mentioned the 
 further exhaustion of a few days of acute insanity is 
 added, and then the stupor comes on. The charac- 
 teristic of the stuporose patient is his stillness. He 
 stands with drooping head and hanging arms, with 
 open mouth and staring lack-lustre eyes, with a face 
 void of expression, in an attitude void of vigour, and 
 thus he stands all day. Speak to him, shout at 
 him, fire a pistol behind him, flick your fingers 
 within an inch of his eyes, you evoke no response ; 
 he exhibits no reaction. Saliva hangs in long ropes 
 from his open mouth, his face is sweaty and greasy, 
 his pupils large, his tongue flabby, his hands blue, 
 his pulse feeble. Of food placed before him he takes 
 no notice, but if it is put into his mouth he will 
 chew and swallow it. Yet, stupid as he is, and 
 destitute of most ordinary reactions, except in the 
 most extreme cases he does not let his urine 
 dribble, nor does he allow his bowels to act inap- 
 propriately. He retains both urine and faeces until 
 he is taken to the closet, and when he is there he 
 passes them. As he passes his days in a state 
 closely allied to profound slumber, so he sleeps well 
 at night. 
 
 Such is the appearance and such are the habits of 
 a well-marked case of stupor. But the condition is 
 not always as well marked as this, and indeed the 
 degrees of stupor are very various. In milder cases 
 the patient moves from place to place of his own 
 accord, though his movements are seldom and slug- 
 gish. He may answer when addressed, but the 
 answer is long in coming, is brief, and is uttered in 
 a faint monotonous voice. He may keep his mouth 
 shut, exhibit palpebral reaction, and even look about 
 
120 TEXT-BOOK OF INSANITY. 
 
 him from time to time ; in short, he may exhibit n 
 less degree of the same condition ; or, in rare cases, 
 the symptoms are not less, but more pronounced. 
 The patient does not stand, does not move under 
 any provocation. He lies like a log; he passes his 
 motions and urine beneath him. He does not even 
 chew his food. His extremities are not only blue, 
 but deathly cold, and the circulation in them is so 
 defective that sometimes sloughs form. His only 
 spontaneous movements are breathing and swallowing. 
 
 While spontaneous movement is absent or mini- 
 mised, the reaction to " passive " or imposed move- 
 ment presents three well-marked variations. In the 
 first class, every attempt to move the limbs or the 
 body is met with obstinate and intense resistance, 
 which is the same to every variety of movement 
 and in every part of the body. It is as pronounced 
 in the jaw as in the arm or leg ; it is as obstinately 
 opposed to flexion as to extension. It is as difficult 
 to make such patients change their attitude from 
 standing to sitting as to make them change from 
 sitting to standing. The same resistance that is 
 opposed to everything else is opposed to the adminis- 
 tration of food ; and of course this is a serious matter, 
 and influences the prognosis, which is worse than in 
 the other forms, though not necessarily hopeless. 
 This obstinate resistance to imposed movement, when 
 present in stupor, is always associated with melan- 
 cholic delusion ; it is present in many cases of acute 
 insanity, and then also is usually associated with 
 melancholy. 
 
 The second and most frequent variation in the 
 reaction to imposed movement in stupor is the 
 " cataleptic " condition, in which there is no resistance 
 
VARIETIES OF INSANITY-STUPOB. 121 
 
 to the imposition of movement, and in which any 
 attitude that we choose to impose upon the patient is 
 retained by him. When the stuporose condition is not 
 very pronounced, the attitude is maintained for but a 
 short time, it may be only a moment or two ; but 
 when the stupor is deep, the attitude will be main- 
 tained for long. We raise the patient's arm over his 
 head, and there it will remain for several minutes. 
 Dr. Clouston relates a case in which a stuporose patient 
 was got out of bed, the chamber pot was put into his 
 hands, so that he held it under his penis, and then the 
 attendant went away and forgot him. He remained 
 in this attitude for several hours. In stuporose cases, 
 in which this cataleptic condition exists, the prognosis 
 is usually favourable. 
 
 The third variation is that in which there is neither 
 resistance to, nor retention of, an imposed attitude, but 
 a flaccid facility. The limbs can be moved with ease, 
 and fall back after movement into such positions as 
 require the least exertion to maintain. This is the 
 condition to which the term " anergic stupor " has 
 been given. 
 
 The mental condition in stupor may be in one of 
 two extreme conditions, or in any intermediate state 
 between them. In simple stupor, of exaggerated 
 degree, consciousness is altogether absent ; at least, 
 we can get no manifestation of consciousness while 
 the state continues, and when it is past, no memory 
 whatever remains of the experiences of the stuporose 
 state. In the minor degrees, consciousness is pro- 
 portionately diminished. Some sign of consciousness 
 can be elicited, some slight reaction can be obtained ; 
 after a question has been many times repeated, some 
 answer will be given ; after an order has been many 
 
122 TEXT-BOOK OF INSANITY. 
 
 times insisted on, some attempt will be made to carry 
 it out ; and when recovery takes place, some glimmer 
 of remembrance will be retained of what occurred 
 during the illness. 
 
 The other form of stupor is called melancholia cum 
 stupore, or melancholia attonita, or melancholy stupor, 
 since in it there is always misery, and sometimes the 
 depression is profound. The depression is somewhat 
 different from that of ordinary melancholia, and is 
 more of the nature of panic or horror. The sense of 
 personal unworthiness and incapacity which constitutes 
 melancholia is, indeed, present, but in addition to this 
 is an overwhelming horror at something that the 
 patient deludedly believes to have occurred, or to be 
 about to occur. Unlike the previous form of stupor, 
 consciousness is not only present, but seems, as it were, 
 to be intensified. The patient is keenly alive to 
 everything that is going on around him, but every- 
 thing that happens is woven into his dream, and goes 
 to corroborate and intensify it. If he is compelled, for 
 instance, to take food, to dress or to undress, to sit 
 down or to walk, this interference is interpreted by him 
 to be the actual beginning of that terrible torture to 
 which he is to be submitted, and the attendants who 
 so interfere with him are his executioners. Hence 
 his stubborn resistance. 
 
 The treatment of stupor may be summed up in two 
 words feeding and rest. The state is .one of exhaus- 
 tion, and the treatment must be directed to restore 
 the exhausted energy. To this end feeding must be 
 copious. Such patients must have much more than 
 the ordinary full diet which would suffice for a healthy 
 person of the same age, and, in young people at any 
 rate, it should be highly nitrogenised plenty of eggs 
 
VARIETIES OF INSANITY STUPOR. 123 
 
 and plenty of meat, with a moderate quantity of 
 alcohol. When solid food cannot be administered, 
 of course slops must be given, but essences and extracts 
 are useless. Milk is always valuable, and when food 
 cannot be given in solid form, it should be given, not 
 as liquid, but as thin porridge, that is to say, with 
 plenty of finely divided solids suspended in it. Bread 
 sauce is an excellent food, and may be mixed with 
 pounded meat. 
 
 Kest is the complement of feeding. Since energy 
 is exhausted, every demand upon energy must be 
 minimised, and therefore the patient should be kept 
 warm, and usually he should be kept in bed. He must 
 be vigilantly watched to prevent masturbation, which 
 often goes on in a quasi-automatic manner ; and 
 sleep, the great restorer of exhausted energy, should be 
 encouraged, and if necessary induced by hypnotics. 
 
 The same indications govern our administration of 
 drugs. Cod-liver oil, Easton's syrup, and other pre- 
 parations of iron, quinine, strychnine, and phosphorus 
 all appear to assist recovery. Baths and friction are 
 useful, but massage is not advisable. 
 
 In simple stupor, the prognosis is usually favour- 
 able. It occurs commonly in young people, in whom 
 recuperative power is active, digestion good, and 
 sleep easily induced; and, moreover, in this form 
 there is neither refusal of food nor exhaustion from 
 struggling during its administration. In melancholy 
 stupor the prospect is much less favourable. It may 
 occur at any age ; sleep is usually difficult to induce, 
 and the strenuous resistance to feeding and other 
 necessary offices keeps a perpetual drain upon the 
 strength. Hence recovery is in this form less frequent, 
 it is longer delayed, and a much larger proportion of 
 
124 TEXT-BOOK OF INSANITY. 
 
 the cases end either in death or in permanent 
 insanity. 
 
 In other characters, as well as in those mentioned, 
 melancholic stupor shades off by insensible degrees 
 into acute insanity, and many cases which would 
 usually be classed as acute insanity exhibit the panic 
 and horror that are so prominent in this form of 
 stupor. When, as not seldom happens, the subject of 
 melancholic stupor exhibits sudden outbreaks of im- 
 pulsive violence, directed either against himself or 
 against others, or similarly impulsive outbreaks of 
 destructiveness, the case approaches in character to 
 ordinary acute insanity ; and the affinity of the two 
 forms of insanity is further exhibited in the occasional 
 transition of the one into the other. The stuporose 
 patient loses his apathy, his outbreaks of excitement 
 become more frequent, and he passes, on his way to 
 chronic quiet dementia, through a period of ordinary 
 acute insanity. 
 
 4. ACUTE DELIRIOUS MANIA. 
 
 This is one of the most definite and clearly dis- 
 tinguished clinical varieties, as distinguished from 
 forms, of insanity one of the few varieties of in- 
 sanity which runs a very definite course. No other 
 variety of insanity exhibits such extreme and con- 
 tinuous excitement as acute delirious mania. Even 
 in acute insanity the patient has his moments of 
 tranquillity; has snatches, perhaps prolonged periods, 
 of sleep ; will occasionally answer questions intelli- 
 gently; will regulate his conduct with some refer- 
 ence, however distorted, to surrounding circumstances ; 
 
VARIETIES OF INSANITY DELIRIOUS MANIA. 125 
 
 will sometimes recognise his friends, and will have 
 some regard to the decencies of life ; but in acute 
 delirious mania the alienation is more profound. The 
 raving is continuous. It goes on incessantly, day 
 and night, the whole twenty-four hours round. It 
 is quite incoherent and meaningless, a torrent of 
 unintelligible utterance. And as is the vocal move- 
 ment, so are the other bodily movements. The 
 restless activity is extreme and incessant ; the patient 
 roams about with ceaseless restlessness, he is never 
 still, he never lies down, he never sits down, he is 
 always on his feet, always in movement. He neither 
 eats nor sleeps ; sometimes he will drink, sometimes 
 not ; but in any case he never eats voluntarily ; 
 and is with the greatest difficulty induced to do so. 
 The length of time that he goes entirely without sleep 
 is astonishing. Day after day and night after night 
 he keeps up his incessant movement. You cannot 
 engage his attention ; he takes no notice when 
 spoken to. He is indifferent whether he is dressed 
 or naked ; heat and cold he does not notice ; the calls 
 of nature he does not answer : his bladder becomes 
 full, and over full, until his urine dribbles away. 
 Withal his temperature is raised ; it is seldom much 
 raised, but it is two or three degrees above normal, 
 and this feature alone distinguishes this from almost 
 every other variety of insanity. Such excessive and 
 continuous waste of tissue and of energy cannot endure 
 long without producing exhaustion. After a few days of 
 this extreme restlessness and sleeplessness, the patient 
 is no longer able to remain on his feet ; he "sinks 
 to the ground, but still he continues to rave in a 
 voice hoarse and well-nigh inaudible from incessant 
 use ; still he continues to toss about MS weary limbs ; 
 
126 TEXT-BOOK OF INSANITY. 
 
 and when this stage is reached, the end is not far off. 
 His mouth becomes dry, sordes accumulate on his lips 
 and teeth, his heart's action fails, his pulse flutters, 
 his breathing becomes a succession of sighs; but still 
 he mutters in a hoarse whisper his unceasing babble, 
 until, at the end of seven or eight days, he dies of 
 exhaustion. Such is the course of a typical case of 
 acute delirious mania, the " brain fever " of older 
 writers, the most rapid and most terrible variety of 
 insanity. 
 
 It affects both men and women, and usually those 
 who are in the prime of life from twenty-five to 
 forty and is usually preceded by some prolonged 
 and efficient debilitating occurrence, such as an ex- 
 hausting illness, deficiency of food, rest, and sleep, 
 anxiety, disappointment, or excessive intellectual 
 labour. 
 
 Acute delirious mania is practically always fatal. 
 If a case is so mild as to admit of recovery, it would 
 be one of acute in sanity -rat her than of acute delirious 
 mania. As to treatment, a padded room is essential. 
 In no other surroundings can the restlessness of the 
 patient lead to so little bruising and other injury. 
 Abundance of food must be given by the stomach 
 tube, and mingled with it should be given brandy, 
 strychnia, and large doses of hypnotics paraldehyde, 
 sulphonal, and trional being the best. For all that 
 we can do, however, the patient will almost surely 
 die ; and in the rare cases in which the bodily 
 health recovers, the patient remains a mental wreck, 
 a hopeless dement for the rest of his days. 
 
VARIETIES OF INSANITY. 127 
 
 5. ACUTE INSANITY. 
 
 The boundary between this and the previous variety 
 of insanity is not always well defined, but generally, 
 the whole course and symptoms of acute insanity are 
 less acute, less rapid, less exaggerated and fulminating, 
 than those of acute delirious mania; recovery is not 
 infrequent ; and what differentiates them more sharply 
 is that in the latter disease the form of insanity is 
 always that of mania, while acute insanity is of several 
 types. 
 
 The causes and antecedents of acute insanity are 
 those of insanity in general. It may occur at any 
 age after sixteen, and in very rare cases before that 
 age, but is most frequent in the most vigorous period 
 of life from twenty to forty-five. 
 
 Acute insanity is rapid, sometimes sudden, in its 
 development. The very first thing to attract attention 
 and to indicate insanity may be a determined attempt 
 at suicide a leap from a window, a cut throat, or a 
 dose of poison, or it may be some outrageous or violent 
 act directed against other people. But usually there 
 is some warning of what is going to happen. For 
 days, or even weeks, beforehand, the patient sleeps 
 little, dreams much and vividly, eats little, finds 
 himself unable to attend to his business, feels ill, 
 and perhaps seeks medical advice. Headache is rare, 
 but often the mind is confused, and the patient dreads 
 lest he should be going out of his mind ; or he gets 
 restless, talks too much, pays too many visits, writes 
 unnecessary letters, sends unnecessary telegrams, 
 neglects or mismanages his own business, and meddles 
 with that of every one else. 
 
128 TEXT-BOOK OF INSANITY. 
 
 After a few hours, days, or weeks of these initial 
 symptoms, the disease becomes fully established, and 
 then exhibits several forms distinguished by the 
 following characters : In the first form the patient 
 is excited that is to say, his movements are in 
 excess ; he talks with rapid fluency and discon- 
 nectedly ; he utters sometimes a stream of words 
 in which each suggests the next by sound or mean- 
 ing, but which are not connected into sentences, 
 such as " window, wind, blow, thrashing, smashing," 
 or they may be connected into sentences which are 
 similarly irrelevant to each other, as " open the 
 window, give me a glass, drink your brandy, isn't he 
 handy ? what a dandy ! fine feathers make fine birds," 
 etc. Together with verbal utterance, other move- 
 ments are in excess, and are similarly disconnected. 
 The patient roams about the room, he rushes to the 
 door or the window, he picks up every movable object 
 and throws it down again, or throws it about the 
 room, or converts it to some use for which it was 
 never intended. He upsets the water-jug and the 
 chamber-pot, he overturns the furniture, he breaks 
 the windows, he throws the chairs about, he assaults 
 those who endeavour to control him, he tears his 
 clothes off, he or she swears, blasphemes, and talks 
 obscenely ; and all this he does, not with any settled 
 or intelligent or enduring purpose, but aimlessly, 
 erratically, and out of the mere exuberance of his 
 energy. 
 
 A second type is the melancholic. In this type the 
 activity is less, and there is a dominant delusion. 
 The patient believes that he is ruined, or that he is 
 damned, or that he has some frightful bodily disease, 
 or that he is morally a hopeless outcast, and to this 
 
VARIETIES ACUTE INSANITY. 129 
 
 belief he gives utterance all day long. He is usually 
 still over-active, though his over-activity is less. But 
 he does not sit down, he does not rest ; he shuffles 
 about the whole day long, giving vent, not with shouts 
 and outcries, as in the previous type, but in a 
 muttering, plaintive, miserable voice, to his conviction 
 of his own ruin, his un worthiness, his incapacity. He 
 weeps, he moans, he wrings his hands, he tears his 
 hair, he beats his breast ; he importunes you for a ray 
 of hope, a glimmer of comfort ; but he refuses to be 
 comforted. He repeats the same formula over and over 
 again a thousand times a day : " Oh ! my poor soul." 
 " I am so wicked ! " "I can't pay you ! " " My poor 
 wife and children!" "Oh! dear; oh! dear." "Oh! 
 my God," and so forth. He is less inclined to the im- 
 pulsive outbreaks that are so common in the previous 
 type, but he is very likely to commit suicide, and he 
 is more persistent and obstinate in his refusal of food, 
 while he is less neglectful of personal cleanliness and 
 less apt to pass his motions and water beneath him. 
 
 A third type is the suicidal. Acute insanity of 
 suicidal type often displays as much restlessness and 
 over-activity as is seen in the first type that of acute 
 mania. In every form of acute insanity attempts at 
 suicide are common events, but in this form the whole 
 attention and energy are concentrated upon the single 
 purpose of suicide. The sufferer from acute mania will 
 try to jump out of the window, or will take up a knife 
 or a razor and cut himself with it, not, as far as can be 
 judged, with any deliberate intention of suicide, or of 
 anything else, but out of pure restlessness and meddle- 
 someness, combined with inability to appreciate the 
 nature and quality of his acts. In this, as in every 
 other type of acute insanity, there is sure to be, at 
 
 9 
 
130 TEXT-BOOK OF INSANITY. 
 
 some time, refusal of food, but the refusal does not 
 appear to be the expression of any deliberate intention 
 of suicide. But in this third variety the whole power 
 of the mind is absorbed in, and devoted to, the single 
 object of suicide. The mind is far more alert than in 
 the other types ; the power of adapting means to ends 
 is retained to a far greater extent ; and the end which 
 is sought with inflexible determination, and with the 
 most flexible adaptation of means, is suicide. To effect 
 this end they are continually on the watch. In every 
 object they see a possible means, and they set them- 
 selves with much ingenious contrivance to reach it, 
 and possess it. They will promise to eat, if they may 
 eat by themselves, hoping thereby to be left alone. 
 They will break glass and crockery to get a cutting 
 instrument ; they will ravel out the threads of their 
 clothing to make a cord which they can tie round the 
 throat ; they will swallow anything that seems un- 
 wholesome ; will bite a piece out of a tumbler or a cup, 
 and try to swallow the fragment ; will batter the head 
 against the wall or floor, and try by the most unusual 
 as well as by the most obvious means to effect their 
 purpose. If they find suicide impracticable, or while 
 they are waiting for a favourable chance to effect it, 
 they will occupy the time with efforts to reduce their 
 comfort and give themselves pain, or even mutilate 
 themselves. They will try to gouge their eyes out 
 with their fingers, to tear the cheek with the finger in 
 the mouth, to tear out the testes or to cut off the penis. 
 Prevented from tying a ligature round the neck, they 
 will endeavour to tie it round the leg or the penis. 
 Prevented from knocking their heads against the wall 
 they will take the skin off their knuckles by the same 
 means, and so on. 
 
VARIETIES ACUTE INSANITY. 131 
 
 A fourth type is the silent, obstinate, resistive. 
 Patients of this type do not speak. When spoken to 
 they do not answer. They make for the door, the 
 window, or the fire, and when restrained will continue 
 for hours the same silent, dogged, determined effort 
 to reach the desired destination. They, too, undress 
 themselves, but they do so, not, as the acute maniac 
 does, from the mere exuberance of their activity, which 
 must find some vent, it matters not what, which, when 
 restrained from taking off the coat, begins to unbutton 
 the waistcoat or trousers. A patient of this type 
 undresses himself with the same blind, dogged obstinacy 
 that he does everything else. He persistently, again 
 and again for hours together, attacks the same button, 
 or tries to remove the same garment in the same way. 
 He, too, refuses food, but he refuses it, not, so far as 
 can be judged, with suicidal intent, but with the same 
 resistiveness with which he stubbornly opposes every- 
 thing that is done for him refuses to be dressed and 
 to be undressed, to be sat down or stood up, to go to 
 the closet and to come away from it, to walk about or 
 to stand still. 
 
 A fifth type of acute insanity is the sexual. A 
 sexual proclivity is usually perceptible, as is the 
 suicidal proclivity, in every case of acute insanity ; but, 
 in the one matter as in the other, there are cases in 
 which the proclivity becomes so pronounced, assumes 
 such dominance, is by so much the most prominent 
 and conspicuous feature, as to constitute a distinct 
 type of the malady. The sexual type is exhibited 
 by women almost exclusively. Few things are more 
 surprising in insanity than the obscenity and filth that 
 are uttered by women, and even by young girls, well 
 bred and carefully brought up, of pure lives, and 
 
132 TEXT-BOOK OF INSANllY. 
 
 previously irmocent conversation and behaviour. They 
 curse and swear like troopers ; they use expressions 
 of obscenity and blasphemy of which a costermonger 
 would be ashamed. Nor is it only in their speech that 
 they display lewdness and indecency. Insane women 
 of this type make shameless overtures to every man to 
 whom they have access. Not the gardener nor the 
 footman ; not the waiter in the hotel in which they 
 are taken ill ; not the medical man who attends them ; 
 not even their own brothers or fathers, are exempt 
 from their libidinous advances. They ogle and leer, 
 they throw themselves into unseemly and indecent 
 attitudes, they expose their breasts and legs, and, when 
 all this is ineffectual, they do not hesitate to ask in 
 plain terms for what they want to call out of the 
 window to a passer-by to come to bed with them, or 
 even, in plain Saxon, to have intercourse with them. 
 As the melancholic and suicidal varieties of acute 
 insanity are often called acute melancholia, so the 
 sexual type is often called nymphomania ; but all are 
 really varieties of the same malady, in which the 
 one or the other feature, common to all, becomes 
 exaggerated and assumes unusual preponderance. 
 
 Whatever the type of the acute insanity, there are 
 certain features common to them all. All, as we have 
 seen, are potential suicides. In all there is at one time 
 or another refusal of food, alternating, it may be, with 
 wolfish voracity. In all there are sexual proclivities, 
 showing themselves in frequent shameless mastur- 
 bation, as well as in other ways. In all there is 
 inattention, not only to ordinary tidiness and clean- 
 liness, but to the calls of nature. They pass their 
 urine and motions under them, either occasionally or 
 habitually, according to the gravity of the case. Their 
 
VARIETIES ACUTE INSANITY. 133 
 
 clothes soon become ragged, dirty, stained, and caked 
 with spilt food. In all cases of acute insanity, sleep- 
 lessness is a very prominent and very important 
 symptom. It has usually existed for days or weeks 
 before the insanity declares itself, and it is aggravated 
 when this takes place. The length of time for which 
 they will maintain their excessive activity without 
 sleep, or with only an hour or two of sleep per night, 
 is astonishing. They are always constipated, and the 
 tongue is usually foul, and the breath stinking. They 
 have usually lost a great deal of weight before the 
 insanity declares itself. When they are sufficiently 
 rational to give an account of themselves, they 
 are found to be suffering from delusions. In the 
 melancholy type these are the ordinary delusions 
 of melancholia, sometimes combined with delusions of 
 persecutory type. In the excited or maniacal type 
 the delusions are of a very extravagant character. The 
 patient has visited heaven and made the personal 
 acquaintance of the Almighty, or he has attended his 
 own funeral, or he has some other equally extravagant 
 belief. Hallucinations are rarely prominent, and often 
 not present in acute insanity, and when present are 
 usually visual. It is rare for patients with acute 
 insanity to " hear voices," and those who do are usually 
 of the resistive type. 
 
 Acute insanity is very variable in course and duration. 
 In a few cases it is very evanescent, and clears up 
 completely and permanently in twenty-four or forty- 
 eight hours ; and such cases constitute what has been 
 called mania transitoria. Usually it lasts in full 
 intensity for from one to four or five weeks, and if the 
 longer term is reached, it then terminates fatally from 
 exhaustion. The earlier improvement begins, the more 
 
134 TEXT-BOOK OF INSANITY. 
 
 favourable the chance of recovery ; the longer the full 
 intensity of the malady lasts, the graver the prognosis. 
 Four or five weeks of really acute mania will kill the 
 strongest man, and a shorter term, even if not fatal 
 to life, is very apt to leave irreparable damage to the 
 brain and mind. Of the five types described, the 
 resistive is the most unfavourable to life, and the 
 suicidal is the most apt to leave permanent insanity. 
 When recovery takes place, it often takes place 
 suddenly. The patient has a night of long, sound 
 sleep, and wakes up well, or so nearly well that a few 
 days completes the recovery ; but this can only happen 
 when the malady has been of sudden onset and short 
 duration. In other cases, improvement is gradual, the 
 excitement subsides, the melancholy clears away, and 
 the patient passes into a state of slight, or it may 
 be of grave, dementia, from which he may gradually 
 emerge, or which may remain permanent for the rest 
 of a long life. In other cases the subsidence of the 
 excitement is simultaneous with fixation and systeina- 
 tisation of the delusions, and the acute insanity merges 
 without break into paranoia. Even when recovery is 
 rapid and appears complete, the patient should not 
 return to the active duties of life for at least a third 
 or half a year, and he will always be liable, on a 
 recurrence of the conditions, to a recurrence of the 
 malady. 
 
 The effective treatment of acute insanity, like that of 
 stupor, which might be made a sixth type of this variety, 
 may be summed up in two words food and sleep. 
 In the rare cases in which a patient has been eating 
 and sleeping fairly well up to the time of the outbreak 
 of insanity, the prognosis is extremely unfavourable ; 
 and the more confidently we can attribute the outbreak 
 
VAKIETIES -ACUTE INSANITY. 135 
 
 to deficiency of food and sleep, the more confidently 
 may we expect that the administration of food and 
 the procurement of sleep will be followed by recovery. 
 As the sleeplessness depends very largely upon the 
 inanition, our first care must be to administer abund- 
 ance of food. The patient must not merely be fed, 
 he must be over-fed. He must have food in super- 
 abundance and excess ; he must have twice or three 
 times as much as would suffice for a healthy man of his 
 age and weight. What he needs is not extract of meat 
 and Brand's essence, and Bovril and Valentine's meat 
 juice, and similar concentrates, but bulky, ordinary 
 food meat and potatoes, bread and butter, rice 
 pudding, and such like viands in great quantity. 
 And here we are met at the outset by two serious 
 difficulties first, that digestion is very frequently 
 disordered, and, second, that the food is very frequently 
 refused. 
 
 The first difficulty we may often disregard. The 
 stomach has perhaps been pampered and humoured for 
 months by discarding first one food and then another 
 that has been thought to disagree with it, and if it is 
 taken firmly in hand and compelled to receive all 
 kinds of bland food, it will do its duty uncom- 
 plainingly. A more serious matter is that when food 
 has for months been taken in small quantity only, the 
 stomach has become contracted, and till it has been 
 educated to receive larger quantities, it will resent 
 over-distention by vomiting. In such cases we must 
 be content to feed very frequently, and gradually to 
 increase the amount given at each meal. 
 
 The other difficulty is far more serious. Pefusal of 
 food, obstinate resistance to the administration of food, 
 is a common feature of all the types of acute insanity, 
 
136 TEXT-BOOK OF INSANITY. 
 
 and unless it is overcome, the patient will certainly die. 
 It must therefore be dealt with promptly and vigor- 
 ously. The patient must be forcibly fed. There are 
 degrees of persistence of refusal. Some patients will 
 not feed themselves, but if the food is put to the 
 mouth, they will take it with docility, chew and 
 swallow it. Others will take it only if spoon-fed ; 
 the rest and these are the majority will refuse and 
 resist every attempt to feed them. Various methods 
 of forcible feeding are in use for such cases, but I 
 have no hesitation in condemning all but one. The 
 nasal tube, a small tube of soft rubber introduced into 
 the nostril, has been used very largely, but it is so 
 easy for a suicidal patient, or even a greatly demented 
 patient, to inhale the food thus administered ; and so 
 many cases of gangrene of the lung have followed the 
 use of the method ; that it ought to be abandoned, and 
 the aesophagial tube used in every case. 
 
 Of course, in this case, solid food cannot be given 
 in solid form ; but the same food can be given if it is 
 first pounded up in a mortar and made into a thin 
 pulp with milk, and then there is the advantage 
 that the appetite and palate need not be consulted, 
 and food, stimulants and drugs can be administered 
 together. If a really copious and excessive amount of 
 food is introduced, the difficulty about sleep is already 
 half overcome ; but there are few cases, though there 
 are a few, in which food alone is sufficient to procure 
 sleep. In most cases hypnotic drugs have to be 
 employed. Our choice of these has greatly extended 
 of late years. There was a time when opium was the 
 only soporific ; then chloral and bromide of potassium 
 were added ; now all these are abandoned in the 
 treatment of acute insanity, and newly discovered 
 
VARIETIES ACUTE INSANITY. 137 
 
 drugs are found to be more efficacious and attended 
 by fewer disadvantages. 
 
 The question often arises, what is to be done upon 
 the instant to control a patient who has suddenly 
 become acutely insane in his own house, or in an hotel, 
 or elsewhere ; who is tearing up his clothes and 
 smashing the furniture, who has worn out his friends 
 and the ex-policeman who has been called in to help in 
 controlling him ? In this state of things we have in 
 hyoscin an agent of the utmost value. It is made up 
 for hypodermic use in minute tabloids, and one of these 
 can be dissolved in a cup of tea or a glass of wine, or, 
 if needs must, it can be given hypodermically, and its 
 action is very speedy and very effectual. The usual 
 doses o-J^ and -fj of a grain are of no use in acute 
 insanity, and at least -$ should be given under the 
 skin, or ^ by the mouth. I give -% hypodermically, 
 and have never seen any ill effects from its use. Ill 
 effects, and fatal effects, used sometimes to attend its 
 use when the drug was first introduced, but no case 
 has been reported of late years, and I cannot help 
 thinking that when it has been fatal, either the drug 
 was impure, or it was insufficiently mixed, and larger 
 doses were given than were intended. At any rate, 
 if there is any risk attached to its use now, it is a risk 
 that ought to be run, for the danger of the drug is in 
 any case not so great as the danger of allowing the 
 patient to die of exhaustion ; and therefore it should be 
 given. In this way a breathing-time may be obtained, 
 during which the friends are freed from the absorbing 
 task of immediate attendance on the patient, and are 
 at liberty to take the necessary steps to have him 
 removed to an institution. For this course is essential 
 in every case of acute insanity, except, perhaps, when 
 
138 TEXT-BOOK OF INSANITY. 
 
 the patient's friends are very wealthy, and can arrange 
 for at least three attendants and a medical man to 
 reside in the house with him, and even then the 
 conditions for his control and recovery are not so 
 favourable as they would be in any well-conducted 
 institution. It is scarcely justifiable to keep up a full 
 administration of hypnotics merely for the purpose of 
 facilitating the control of a patient, and unless this is 
 done, there will be times when two, and even three, 
 attendants will be insufficient to control an acute 
 maniac. He should be in a place where practically 
 unlimited help can be brought to bear to get him 
 undressed, or dressed, or fed, as the case may be. 
 There is nothing so likely to produce bodily injuries 
 as insufficiency of help in these operations. 
 
 There is a practical measure of great value, which is 
 much insisted upon by Dr. Savage in the management 
 of acute insanity so long as the patient is kept at 
 home, and this is to remove the patient at once to the 
 ground floor, bag and baggage, bed and bedding. 
 Then if he jumps out of the window he can do himself 
 but little harm. 
 
 Useful as hyoscin is as a calmative and controller of 
 excitement upon emergency, it is not a drug to be used 
 as an hypnotic, nor is it suitable for prolonged adminis- 
 tration, for tolerance is soon established, and the dose, 
 to be effectual, has to be increased. When we desire 
 an hypnotic effect, the most efficient drug for ordinary 
 use in acute insanity is sulphonal, a drug that has the 
 great advantage that it not only induces sleep at night, 
 but has a calmative influence upon the patient for the 
 following day. Its disadvantages are various. In the 
 first place, its action is delayed, and it varies much in 
 the period after administration at which its effects 
 
VARIETIES-ACUTE INSANITY. 139 
 
 begin to be felt. Sometimes it will act in an Lour, 
 sometimes not for two, three, six, or as much as twelve 
 hours. It is therefore manifestly inappropriate when 
 we desire an immediate effect. Trional, upon the 
 other hand, is a drug whose action is far more speedy, 
 almost as effectual, and much less lasting. It has none 
 of the delayed calmative effect that is so characteristic 
 of, and important in, sulphonal. The best effect of 
 both drugs is obtained by a combination of the two. 
 A combination of about J trional with f sulphonal is 
 most valuable. The trional puts the patient to sleep, 
 and the sulphonal keeps him asleep ten grains of one 
 to fifteen grains of the other, or better, fifteen grains of 
 the one to twenty-five of the other. If this is given 
 the first night, a less dose will suffice for the second, a 
 still smaller for the third, and on the fourth night the 
 patient will usually sleep without drugs. The same 
 hypnotic should not be given for long together. They 
 are much more effectual when changes are rung upon 
 them. In the melancholic form of acute insanity, and 
 when there is cardiac weakness, paraldehyde is a very 
 valuable hypnotic. 
 
 Mention has already been made of the disorder of 
 digestion that is so frequent in acute insanity. In any 
 case in which it is ascertainably present, it must be 
 treated. There are cases in which the contents of the 
 stomach undergo putrefactive or fermentative changes 
 which render them unspeakably foul and offensive, and 
 when this is the case, or whenever the breath is very 
 foul, or especially when foul gases are expressed from 
 the sesophagial tube when the end reaches the stomach, 
 benefit will be derived from washing out the stomach 
 at regular intervals. 
 
 In all cases of acute insanity, certainly in all which 
 
140 TEXT-BOOK OF INSANITY. 
 
 are seven* or prolonged, institution treatment is 
 essential. In many cases it is far better for the patient 
 to have the comparative freedom of a padded room 
 than to be perpetually checked and interfered with by 
 attendants. 
 
 The first favourable symptoms are the establishment 
 of natural sleep, the voluntary taking of food, sub- 
 sidence of excitement, and commencing appreciation 
 by the patient of his circumstances. If all these are 
 concurrent with a gain of weight, and occur within the 
 first fortnight, there is reasonable hope of complete 
 recovery. But if sleep is established, food taken, and 
 weight gained, while still the mind does not improve, 
 the prognosis, while improved as to life, is very gloomy 
 as to recovery of reason ; and if improvement is 
 delayed beyond the first fortnight, every day's delay is 
 of serious consequence. 
 
 6. FIXED DELUSION. 
 
 This is a very well characterised and very frequent 
 variety of insanity, but is not often seen outside of 
 asylums. It is one of the terminations of acute 
 insanity, and the patient, who had been admitted for 
 the acute malady, is retained for the rest of his life for 
 the fixed delusion and the accompanying dementia, in 
 which it ends. 
 
 The character of the delusions is various, but 
 commonly they are delusions either of exaltation or 
 of alteration of part of the self. To this variety of 
 insanity belong practically all the kings, queens, 
 emperors, and millionaires who are not general para- 
 lytics, and to this also belong the people who have 
 weasels, wolves, or crabs in the stomach, glass legs, no 
 
VARIETIES FIXED DELUSION. 141 
 
 backs to their heads, whose brains have been taken 
 out, and who suffer from other changes of the 
 personality. 
 
 The distinguishing feature of the insanity is that the 
 delusion has practically no effect upon conduct. The 
 kings and emperors are content to pass their lives 
 in the most menial occupations, scrubbing floors and 
 carrying coal : the queens and duchesses work con- 
 tentedly in the laundry ; the millionaires see nothing 
 inconsistent with their wealth in holding a horse for a 
 copper, or begging for a bit of tobacco. What inca- 
 pacity they have for more intelligent employment 
 and the incapacity is often considerable they owe to 
 their dementia, and not to their delusion. The 
 delusion is not often prominent. It does not absorb 
 much of the attention of the patient. He does not 
 obtrude, it and make himself a nuisance by worrying 
 about it in season and out of season, as the paranoiac 
 does. He is often rather reticent about it, and has to 
 be questioned and cross-examined before he will confess 
 to it; but once started on the subject, he is usually 
 difficult to stop. In any case, not only does it not 
 influence his conduct, but it does not much affect the 
 rest of his mind. The king and the millionaire do not 
 appear particularly elated by the knowledge of their 
 exalted position or their wealth. The man whose legs 
 are of glass, or whose stomach is tenanted by an 
 unbidden guest, does not worry about crural fragility 
 or his parasite. The delusion forms a small and 
 unimportant part of his mental life, and he pursues 
 the tenour of his way without regarding it. A large 
 number of the inmates of lunatic asylums exhibit this 
 variety of insanity. 
 
 The bodily state exhibits nothing characteristic. 
 
14-2 TEXT-BOOK OF INSANITY. 
 
 The malady is essentially chronic, unchanging, and 
 irrecoverable. The patients remain in the same state 
 of dementia and delusion for the rest of their lives ; 
 liable, like other dements, to outbreaks of excitement 
 from time to time ; subject to the common ailments of 
 humanity, of one of which, in the fulness of time, 
 they die. 
 
 7. PARANOIA. 
 
 This is both a form and a variety of insanity : that 
 is to say, it is not only well characterised as an existing 
 state, but the state is confined to a single variety of 
 insanity, which runs a definite course, and it is not 
 seen in any other variety. By a systematised delusion 
 is meant a delusion which, to use the language of 
 modern psychology, constitutes an " apperceptive 
 system." It is an organised body of (false) knowledge, 
 and it differs from other delusions in the fact that it 
 colours the whole life of the patient ; it regulates his 
 daily conduct ; it provides him with an explanation of 
 all his experiences that are otherwise inexplicable ; it 
 is his theory of the cosmos. 
 
 For instance, his delusion is that he is influenced by 
 telephones. Whatever he does, and whatever happens 
 to him, that is in the least out of the ordinary course, 
 is due to the telephones. He sees a pretty flower, and, 
 forgetful of the regulations in that case made and 
 provided, he plucks it ; then he remembers the rule 
 against picking flowers. It was the telephone that 
 made him pick it. Intent upon the beauty of some 
 floral gem, he trips over a grass verge ; it was the 
 telephone that made him trip. He sits down to write, 
 but finds his mind confused ; telephones again. He 
 
VARIETIES PAEAN OIA. 143 
 
 plays whist, and revokes ; the telephone made him do 
 so. He plays billiards and loses ; the telephone kept 
 his balls out of the pockets and put his adversary's in. 
 His nose begins to bleed ; the telephones did it. He 
 gets annoyed and throws his book across the room ; the 
 telephone prompted him, or possessed him and threw 
 the book for him. He sees two strangers meet and 
 chat on the opposite side of the street ; the telephone 
 is talking to them about him, or they are talking to 
 him through the telephone, or the telephone is mixed 
 up with them in some mysterious way. 
 
 The precise character of the systematised delusion is 
 very widely different in different cases, but in all there 
 are several features in common. Through every 
 systematised delusion there runs the thread of perse- 
 cution, which connects them all together in a single 
 well-characterised group. Every systematised delusion 
 is a delusion of persecution. The influence, whatever 
 it be, that acts upon the patient, is always an influence 
 adverse to him. Secondly, the delusion is a fixed 
 delusion; it endures without material change, often 
 without appreciable change, for years and years. 
 Thirdly, it is associated more closely and more con- 
 spicuously than any other form of delusion with 
 confusion of thought. Fourthly, more often than any 
 other delusions it is associated with hallucination. 
 
 The character of the delusion is very various, though, 
 as has been said, the idea of persecution runs through 
 them all. The persecutor may be a specific individual, 
 and in that case may have a real existence or be wholly 
 imaginary. In a certain case, e.g., the patient was 
 annoyed by a man whom he had never seen, but whose 
 presence he felt, whose name was Girardot, and who 
 haunted the lanes and fields about the patient's resi- 
 
144 TEXT-BOOK OF INSANITY. 
 
 deuce, armed with an apparatus of mirrors and lenses 
 by which he was enabled to see at all times what the 
 patient was doing, and to locate him so accurately 
 that he could pour upon him without fail a stream 
 of electricity, whicli produced baleful effects. Not 
 infrequently the persecutor is identified as the 
 superintendent of the asylum, or the governor of the 
 gaol, in which the patient has been detained, and who 
 still, by his emissaries, torments the patient, years 
 after the latter has been transferred to other care. 
 They haunt the neighbourhood; they are under the 
 floor, in the cellars ; they are in rooms above, or on the 
 roof ; they are in adjoining rooms ; every mishap, every 
 inconvenience, every disappointment that happens to 
 the patient is ordered by them. Or the persecutors 
 are not specifically identified, but pervade the com- 
 munity. The people in the streets talk to each other 
 about him ; they look at him in meaning ways ; if 
 they smile or laugh, it is in contempt or derision of 
 him ; if he catches scraps of their conversation, this 
 also has reference to him. He sees two men meet who 
 are total strangers to him ; they shake hands, they 
 smile, and ask each other how they do ; the shake of 
 the hands is a Masonic grip by which each recognises 
 that the other is in the plot; the smile is an ex- 
 pression of triumph that they have succeeded in their 
 nefarious design against him ; the question and answer, 
 while seemingly innocent, really refer in some way 
 to him, and means that he is a blasphemer, a 
 murderer, an adulterer, or what not. In some cases 
 the delusion is of bodily disfigurement ; for instance, 
 the nose is too large, is so large as to attract attention, 
 and the universal topic of conversation, wherever the 
 patient appears, is the size of his nose. 
 
VARIETIES-PARANOIA. 146 
 
 Very often the delusion is of being followed about 
 and watched, it may be by the police, but more often 
 by unofficial watchers. Sometimes the vigilant enemy 
 is a single specific individual, sometimes two or more, 
 sometimes a number of unspecified individuals. 
 
 Perhaps the commonest of all the forms of perse- 
 cutory delusion is that of being acted upon by some 
 unseen influence ; and usually the latest conspicuous 
 discovery in physics is pressed into the service, and 
 becomes the persecuting agent. In the early part of 
 the last century, paranoiacs were persecuted by steam 
 engines ; later, the telegraph was the means of their 
 persecution ; then, as successive discoveries were made, 
 electricity, hypnotism, mesmerism, animal magnetism, 
 telephones, the Rontgen rays, and wireless telegraphy 
 were made responsible for their sufferings. The 
 majority still ascribe their persecution to electricity, 
 and the " electrics " constitute the largest class of 
 paranoiacs. But they are assiduous readers of the 
 newspapers, for they see in the daily prints references 
 to themselves in the items of news and in the leading 
 articles; and whenever a new physical discovery is 
 announced, it is appropriated by them as a means of 
 persecution, and the more obscure it is in its nature, 
 the less they are able to understand of the new process, 
 the more it commends itself to them as a persecuting 
 agent. This seems to be the ground upon which 
 electricity is so often selected. Sometimes, however, 
 nothing sufficiently mysterious exists among the known 
 natural agents, and then a new agent is invented to 
 account for the sufferings. Dr. Conolly Norman gives 
 an instance of a patient who ascribed his persecution to 
 a "typhone," and of another whose thoughts were 
 " read by a hypophone and translated into logarithms." 
 
 10 
 
146 TEXT-BOOK OF INSANITY. 
 
 A patient complained to me that lie was persecuted 
 by " infernal traces mystery " ; another was annoyed 
 by " injury stuff like smoke " ; and another by 
 microscopical glasses. 
 
 While it is not very uncommon for the centre of the 
 persecution to be some bodily peculiarity the large 
 nose or the deformed mouth, which attracts the 
 attention of bystanders, and sets them talking about 
 it, and nudging each other as the patient goes about 
 the streets it is more common for the mysterious 
 influence to be exerted upon the mind. Other people 
 read their thoughts, or think their thoughts, or put 
 thoughts into their minds, or deprive them of the 
 power of thinking, or say or do things through them 
 which they would not say or do of themselves. 
 
 Delusions of persecution are always associated with 
 confusion of mind. No doubt with all delusions there 
 is more or less confusion, or the delusion would not 
 continue ; but in no case is the confusion of mind so 
 conspicuous and complete as it is in cases of paranoia. 
 The delusion is in no case so clearly defined, so sharply 
 cut, so definite in expression, as it is in the delusions, 
 for instance, of melancholia and of exaltation. The 
 confusion is often conspicuous in the very statement 
 of the delusion itself, as in the case of the man who 
 was persecuted by " infernal traces mystery," or when a 
 man is referred to in terms which he cannot repeat, by 
 persons whom he has never seen, under circumstances 
 that he cannot identify ; but if the delusion itself 
 appears to be definite, as when the persecution is the 
 utterance of specific expressions by a specified person, a 
 little conversation, a little questioning of the patient, 
 will nearly always elicit a statement which is a mere 
 farrago of nonsense, an unintelligible jumble of words. 
 
VARIETIES PARANOIA - 147 
 
 Hallucinations are more constant and more promi- 
 nent in paranoia than in any other variety of insanity. 
 They may be referred to any of the senses, and are by 
 far most frequently auditory, and least often olfactory. 
 Visual hallucinations rank next in frequency to 
 auditory, gustatory come next, but are rare, and the 
 olfactory and those of common sensation rarest of all. 
 
 Auditory hallucinations are the most frequent of all, 
 and are of serious import in three ways. In the first 
 place, the " voices " are often minatory, abusive, and 
 objurgatory, and when this is the case they may lead 
 the patient to retaliate with violence upon some 
 innocent bystander or passer-by to whom he attributes 
 them. In the second place, the " voices " are often 
 mandatory and imperative, or persuasive and urgent. 
 They command or they incite the patient to do things, 
 and the acts thus proposed to him are often objec- 
 tionable, criminal, or even murderous in character. 
 They are usually resisted and repelled, but if they 
 continue, as they usually do, for a long time, the 
 resolution of the unfortunate patient at last breaks 
 down, and he commits the act to which he has so 
 long been urged. In the third place, the existence 
 of auditory hallucinations gives a very unfavourable 
 colour to the prognosis of any case in which they are 
 well established. This is true, however, in increased 
 degree, of other forms of hallucination. Auditory 
 hallucinations are occasionally heard on one side only. 
 Sometimes the voice is always the same, sometimes two 
 or more voices are heard, and in some cases they argue 
 with one another, and in that case one may abuse and 
 the other defend the patient. The sufferer usually 
 recognises completely at first the unreal character of 
 the voice, and that it is not produced by any external 
 
148 TEXT-BOOK OF INSANITY. 
 
 agent ; and afterwards, even although he may attribute 
 the voice to bystanders, there is evidently some quality 
 by which he distinguishes it from the voices of real 
 people, for he always speaks of it as " the voice " and 
 " the voices." Deafness is, of course, no bar to the 
 occurrence of auditory hallucinations. 
 
 Visual hallucinations are much rarer, upon the 
 whole, than auditory, though they are much commoner 
 as epileptic aurse, which stand on quite a different 
 footing from the hallucinations of paranoia. These are 
 usually quite elaborate, and may consist of faces or 
 figures those of delirium tremens have often been 
 described or sometimes they consist of words or 
 sentences, luminous or not, standing out as if printed 
 upon the surface of whatever the patient is looking at. 
 In such cases the words are usually of the same 
 character as the " voices " in auditory hallucination 
 that is to say, they are blasphemous or objurgatory or 
 obscene. 
 
 Evil tastes and smells are sometimes, but rarely, 
 complained of. The taste is always disagreeable, 
 usually metallic, and the smell offensive. One patient 
 complained to me that he "smelt blood." 
 
 How far the frequent sexual delusions of the 
 paranoiac are dependent upon hallucinatory common 
 sensation it is impossible to say, but if they are so 
 dependent, hallucinations of this class would be among 
 the most frequent, for nothing is more common than 
 for female paranoiacs to complain of being raped and 
 outraged in complex and horrible ways, and for male 
 paranoiacs to complain of sodomy and various sexual 
 tamperings being practised upon them. 
 
 The conduct of the paranoiac is dominated by his 
 delusion. In this is the marked and conspicuous 
 
VARIETIES PARANOIA , 149 
 
 difference between paranoia and mere fixed delusion. 
 In the latter, the patient goes about his work like an 
 ordinary mortal, and refers to his delusion at intervals 
 only, between which there is nothing to distinguish 
 his conduct from that of a sane person. But the 
 delusions of the paranoiac dominate his whole life. 
 They are with him every hour and every minute of the 
 day. They keep him from his work, they interfere 
 with whatever he tries to do. However he is occupied, 
 he feels the electric shocks, he hears the voices 
 abusing him or conspiring against him, he is con- 
 scious of the vapours pouring upon him, and under 
 these circumstances he cannot work, he cannot 
 maintain any steady employment. If we watch him, 
 we see him twitch, start, and jump, as the shocks affect 
 him, or we notice his expectant attitude ; we see him 
 absorbed in contemplation of his visions, or we hear 
 him answer and expostulate with his hallucinatory 
 voices. Another thing that prevents him from pur- 
 suing his business is the necessity of avoiding his 
 persecutors. To this end, he eschews going out in the 
 daytime ; he cannot remain long in one residence ; he 
 frequently and suddenly changes his lodging ; if he is 
 well-to-do, he travels from country to country to escape 
 from the annoyances, hoping in each to find more 
 efficient police, able to give him protection. But the 
 most important character of the conduct in persecutory 
 delusion is the tendency to violence and to homicide 
 that so often exists. The continuance of the perse- 
 cution, the futility of all measures taken against it, 
 the refusal of the authorities to interfere, the general 
 neglect of, and disbelief in, his trouble, at last generate 
 a degree of exasperation which prompts, it may be to 
 violence, it may be to murder. When the persecutor 
 
150 TEXT-BOOK OF INSANITY. 
 
 is identified with any specific person, the violence is, 
 naturally, directed against that person ; but when, as 
 so often happens, no accessible person or no specific 
 individual is identified as the persecutor, then the 
 violence may be directed against any one, and is usually 
 directed against some person in a prominent position, 
 the avowed motive being " to draw attention to the 
 case." In some cases the hallucinatory voices prompt 
 the patient to commit some deed of violence ; ho 
 resists for weeks or months, but at last, in a fit of 
 exasperation, his resistance gives way, and he does 
 what he is told. In rare cases, the violence thus 
 instigated may be directed against himself; but, 
 intolerable as the life of the paranoiac is made by his 
 persecution, he very rarely finds refuge in suicide. 
 
 The bodily state of the paranoiac offers nothing 
 remarkable. There is no doubt that they do suffer 
 torments from abnormal sensations of various kinds, 
 but we can never discover any justification for these 
 sensations in an altered bodily process. 
 
 In its relations to other forms of insanity, paranoia is 
 nearest to obsession. It differs sharply from melan- 
 cholia in thatfalthough the patient is made miserable 
 by his sufferings, he resents his injuries with rooted 
 indignation. He has none of the conviction of his own 
 unworthiness and incompetence which characterises the 
 despair of the melancholic. Though his delusion is 
 fixed, it differs from the state of fixed delusion in the 
 preponderant influence which the delusion exercises 
 upon conduct. 
 
 Paranoia is sometimes a sequel to an attack of acute 
 insanity, but often it is an original malady, arising 
 gradually and becoming gradually intensified for 
 months or years before it is recognised. Usually a 
 
VARIETIES RECURRENT INSANITY. 151 
 
 family history of insanity can be traced, but this is far 
 from invariable. It is an incurable and irrecoverable 
 malady. As age advances, the prominence of the 
 delusion subsides, and in rare cases the patient can be 
 trusted to resume his place among his fellow-men, but 
 such cases are vory few indeed. The broad general 
 rule is that paranoia is irrecoverable. Curative treat- 
 ment there is none. When we find syphilis among the 
 antecedents of the disease, the syphilis should be 
 treated, but we must not expect the treatment to affect 
 the insanity. 
 
 The need of restraint in an institution is more 
 imperative in paranoia than in any other form of 
 insanity, and the rule is stringent that no paranoiac 
 should be allowed at large. If he is so allowed, his 
 perpetration of a murder is merely a matter of time, 
 and is certain to take place if time be allowed. 
 Scarcely a week, and never a month, passes in which 
 the newspapers do not report a murder committed by a 
 person suffering from this form of insanity and one 
 who obviously ought to have been placed in an asylum 
 years before. 
 
 8. RECURRENT INSANITY. 
 
 Insanity, like every other organic process, exhibits 
 periodicity. In every case of insanity that is at all 
 prolonged, a certain rhythm of exacerbation and 
 subsidence can be detected. Epilepsy, and the in- 
 sanity associated with it, are conspicuous instances of 
 periodicity, more or less regular. In general paralysis, 
 the alternation of periods of excitement and of calm 
 is usually a well-marked feature of the disease. In 
 melancholia, the depression is most intense in the 
 small hours of the morning. In mania, the excitement 
 
152 TEXT-BOOK OF INSANITY. 
 
 is often greatest in the early hours of the night ; and 
 more or less of periodicity of the most various length 
 of cycle can be detected in all cases of insanity. There 
 are certain cases in which different forms of insanity 
 follow one another in regular series, which is repeated 
 again and again, and to this variety of insanity the 
 names folie circulaire, circular insanity, and folie a 
 double forme have been given. It is usually described 
 as a period of depression, or melancholia, followed by 
 a period of excitement approaching, or attaining to, 
 acute mania, from which recovery takes place, to be 
 followed in time by melancholia again, and the cycle is 
 then repeated. The events do not always follow this 
 order, however. Sometimes the excitement precedes 
 the period of depression. Often the period of recovery 
 is not one of complete recovery, but one of mild 
 dementia, and the degree of dementia may be so 
 considerable as to necessitate the permanent detention 
 of the patient in an institution. Then the case 
 becomes one of ordinary dementia, with the periodical 
 outbreaks of excitement which are so common in 
 dementia, and with periods of depression of only slight 
 degree sandwiched between them. In many cases the 
 patient recognises the nature of his malady, and, when 
 he feels it coming on, he voluntarily seeks the pro- 
 tection of an institution, from which he returns when 
 the attack is over to resume the business of life. The 
 most difficult and unhappy cases are those in which 
 the degree of the excitement is just insufficient to 
 allow of the certification of the patient, and he remains 
 at large in a state of sub-acute mania, dissipating his 
 property and bringing scandal upon his name, until 
 the period of depression sets in, to plunge him into 
 agonies of remorse. 
 
VARIETIES INSANITIES OF REPRODUCTION, ins 
 
 There is a variety of circular insanity in which the 
 period of depression is replaced by a period of stupor, 
 usually of the resistive type, and to this variety the 
 name of Katatonia has been given. 
 
 The symptoms of recurrent insanity at any given 
 time are the symptoms of the particular form of 
 insanity that the patient then exhibits, and the 
 treatment corresponds. The prognosis is very un- 
 hopeful. The interval of lucidity or of sanity does 
 not usually become shorter, but the recovery therein 
 becomes less and less complete, until a definite state 
 of dementia takes its place in the cycle. 
 
 The period of the cycle varies much in different 
 cases. In many of the chronic inmates of asylums a 
 periodicity of a few weeks can be recognised in the 
 outbreaks of excitement ; but in what would be called 
 folie circulaire, the intervals may be equal or unequal, 
 the rule being for the period of tranquillity and 
 comparative mental health to be considerably longer 
 than those of depression and excitement, which are 
 approximately equal, and may be one, two, or three 
 months or more in duration. 
 
 9. INSANITIES OF REPRODUCTION. 
 Insanity of Pregnancy. 
 
 It is remarkable that although all women are 
 so liable during pregnancy to emotional disturbances, 
 unprovoked " hysterical " laughing and weeping, 
 " longings," caprices of all kinds, and other mental 
 disturbances, yet disturbance to the point of actual 
 insanity is rare in pregnancy. When it does occur, it 
 occurs either about the third month, as an exaggeration 
 
154 TEXT-BOOK OF INSANITY. 
 
 of the longings and caprices that normally appear 
 then, or about the sixth month, or later, it comes on 
 gradually as the foetus grows. The latter variety is 
 the more frequent and the more severe, the first 
 variety sometimes recovering in the later months of 
 pregnancy, while the latter never recovers until after 
 delivery. 
 
 The form of the insanity of pregnancy is an acute 
 or sub-acute insanity of melancholic type, with suicidal 
 inclination. The delusions are oftened coloured by 
 the condition of the patient, who imagines that she 
 herself or her husband has been unfaithful, or has other 
 delusions in which the husband is concerned, as that 
 she has ruined him. 
 
 As already said, when the insanity comes on about 
 the third month after the pregnancy, it may recover 
 before delivery; but when it comes on in the later 
 stages, it never recovers till the child is born. In 
 a minority of cases the birth of the child, whether 
 prematurely or at term, is followed by rapid recovery; 
 in other cases the insanity continues without change ; 
 and in yet a third class it undergoes an exacerbation 
 a few days after labour, as if puerperal insanity were 
 added to that of pregnancy. Hence the rule is not to 
 bring on premature labour in the hope of terminating 
 the insanity by that means, but the rule ought by no 
 means to be slavishly adhered to in all cases. In some 
 cases, and especially when the insanity is very acute 
 and severe, it is justifiable, and is followed by speedy 
 recovery. 
 
 The treatment of the insanity of pregnancy is that 
 of acute insanity of melancholic type, but with this 
 difference that since whatever drugs are given to the 
 woman are given to the child in her womb also, the 
 
VARIETIES-INSANITIES OF REPRODUCTION. 155 
 
 administration of drugs is to be cautious, and is to be 
 minimised. As in other varieties of insanity connected 
 with reproduction, the prognosis in not unfavourable. 
 About three-fourths of the cases recover. 
 
 Puerperal Insanity. 
 
 The puerperium is one of the commonest occasions of 
 insanity in women, occurring in about a quarter per 
 per cent, of all confinements, and being responsible for 
 about seven per cent, of all cases of insanity in women. 
 It is most common in primiparse and within the first 
 week after labour, it is less common in the second week, 
 and after that time it is rare ; but insanity occurring 
 within six weeks of labour is still called puerperal, and 
 partakes of the character of puerperal insanity. Should 
 insanity occur after this period, it is the insanity of 
 lactation. 
 
 Puerperal insanity is always an acute insanity, and 
 may be of any of the types of that malady that have 
 been described, or of some intermediate grade between 
 two or more of them, but usually it is maniacal-melan- 
 cholic in character. In addition to the description that 
 has already been given of acute insanity, there are cer- 
 tain characters special to the puerperal variety. The 
 impulsive violence so often seen in acute insanity 
 is, in puerperal insanity, usually directed against the 
 infant, which should be immediately removed to a place 
 of safety. Often, but by no means always, there is a 
 septic element in the disease. The lochia become offen- 
 sive, the uterus is tender, the temperature is raised, the 
 pulse rapid and weak, the lips are dry and the tongue 
 foul. In such cases the uterus must be examined, 
 and, if necessary, cleaned out, and the usual sanitary 
 
156 TEXT-BOOK OF INSANITY. 
 
 precautions taken. In other respects the treatment 
 is that already prescribed for acute insanity. 
 
 The treatment is usually successful, perhaps because 
 the patients are always got under treatment early. It 
 is usually necessary to remove the patient to an institu- 
 tion, and here she commonly recovers. The recovery is 
 often interrupted by relapses, sometimes serious, though 
 usually slight, and for this reason, and because the 
 relapse is likely to be much more serious at home 
 than in an institution, and especially because, even 
 when recovered, the patient ought not for several 
 months to resume marital relations, the stay at the insti- 
 tution ought to be prolonged. The subjects of puer- 
 peral insanity often recover with apparent completeness 
 in three months; but they should rarely be allowed 
 to go home before the child is six months old. A 
 rough practical rule is not to discharge the patient 
 until menstruation is re-established, but this will not 
 always work, although the re-establishment of menstrua- 
 tion is often the sign of complete recovery, and a con- 
 siderable mental improvement occurring at the same 
 time is of excellent augury. But when no improvement 
 accompanies the occurrence of a menstrual period, the 
 prognosis is bad. 
 
 Puerperal insanity is remarkable as being the only 
 form of insanity, except acute delirious mania, in which 
 the temperature is raised, except from accidental causes. 
 
 Insanity of Lactation. 
 
 This is an insanity of starvation, of exhaustion. It 
 occurs mainly in the later months of suckling, and 
 among women who suckle their babies freely and long, 
 work hard, and are perhaps, in addition, insufficiently 
 
VAKIETIES-INSANITY OF TIMES OF LIFE. 157 
 
 fed ; and is rare among the well-to-do. Agreeably to 
 its causation, it is an acute insanity of melancholic 
 type (which see), and is very amenable to treatment. 
 Fully three-fourths of the cases recover. 
 
 Insanity of the Climacteric. 
 
 This is a sab-acute insanity, often becoming acute, 
 of gradual onset, and always of melancholic type, asso- 
 ciated with suspicion and terror, and with attempts at 
 suicide. The patient is very apt to have delusions of 
 suspicion, as distinguished from delusions of persecu- 
 tion. She thinks her food is poisoned, that something 
 dreadful is going to happen, or has happened ; that 
 she has lost all her money, and perhaps been robbed of 
 it. Sometimes the delusions have a sexual colouring. 
 An old maid thinks she has been seduced, she has been 
 unchaste, she is engaged to this man or that, to whom 
 perhaps she has never spoken. There is nothing special 
 in the treatment. The prognosis is not unfavourable, 
 but the duration of the disease is likely to be longer 
 than in the insanities connected with child-bearing. 
 In these we expect recovery to take place, if at all, 
 within a year, and often within six months. In the 
 insanity of the climacteric it is unwise to expect re- 
 covery under eighteen months or two years. 
 
 10. INSANITY OF TIMES OF LIFE. 
 
 At puberty, in spite of the important revolution that 
 then takes place in the economy, the occurrence of 
 insanity in a previously sane boy or girl is extremely 
 rare. In the few cases that have been observed it has 
 been an acute insanity and very recoverable. 
 
158 TEXT-BOOK OF INSANITY. 
 
 At adolescence that is to say, from eighteen to 
 twenty-five insanity is very much more common. The 
 factors which contribute to the occurrence of insanity 
 at this age have already been considered. It is pre- 
 eminently the age at which stupor occurs; but the 
 adolescent insane are far from being all examples of 
 stupor. Where the insanity is not stuporose, it is 
 almost always the maniacal type of acute insanity, 
 usually more associated with exaltation than is this 
 malady in older persons. There is nothing special to 
 record as to treatment, except that in these cases the 
 feeding must be even more superabundant than in 
 older adults. 
 
 Senile insanity is a sub-acute, or sometimes an acute 
 insanity, usually of maniacal type, sometimes melan- 
 cholic, associated with much dementia, with great loss 
 of memory of the kind already described, and very 
 irrecoverable. In few varieties of insanity are restless- 
 ness combined with outbreaks of temper so prolonged 
 as in senile insanity. They may continue for many 
 months. The loss of memory for substantives, which 
 is so characteristic of senility, is often, in senile insanity, 
 exaggerated into well-marked aphasia. The outbreaks 
 of peevishness, ill-temper, and futile violence which 
 are so common are sometimes replaced by attacks of 
 panic, in which the patient will scream that he is being 
 murdered, when in fact no one is touching him or is 
 very near him. 
 
 11. INSANITY FROM ALCOHOL. 
 
 The various forms of insanity that alcohol may 
 produce, according to the quantity taken and the time 
 over which it has been administered, have already been 
 
VARIETIES-INSANITY FllOM ALCOHOL. 159 
 
 enumerated; they are: (1) Drunkenness, which may 
 be of various types bragging, suspicious, maudlin, or 
 furious the last being sometimes called delirium 
 ebriosum ; (2) Delirium tremens ; (3) Alcoholic in- 
 sanity, ordinarily so termed ; and to these may be 
 added (4) the moral and intellectual degradation, short 
 of actual insanity, that is observable in all chronic 
 drunkards. It is with the third form that we are now 
 concerned. 
 
 It occurs in men who have habitually for many years 
 drunk too much. During all this time they may 
 never once have been drunk in the ordinary sense of 
 the word, certainly not very drunk, but every day they 
 have taken a considerable quantity of alcohol, enough 
 to have rendered drunk a person of ordinary suscepti- 
 bility to the immediate influence of alcohol. This has 
 gone on for years and years it may be ten, it may be 
 twenty and latterly they have undergone the moral 
 and intellectual degradation that drunkards undergo. 
 They have become liars, they have become indifferent 
 to the means by which they get their drink, so that 
 they get it. They sponge upon others, they run into 
 debt, they frequent low company, they sink in the 
 social scale, they become unfit to associate with ladies 
 and gentlemen, they become a reproach and a byword 
 among their families and friends. On first rising in 
 the morning they retch violently ; their eyes become 
 watery and their hands tremulous. When these con- 
 firmatory signs of long-continued drunkenness appear, 
 insanity is not far off, and may occur at any time. 
 
 The insanity of chronic alcoholism is usually character- 
 ised by suspicion, by delusion, by disorder of memory, 
 and by hallucination and various sensory disturbances 
 and motor defects. 
 
160 TEXT-BOOK OF INSANITY. 
 
 Suspicion is usually a prominent feature in alcoholic 
 insanity. The patient believes that his food is 
 poisoned, that his wife is unfaithful, that his children 
 are conspiring against him, that he is to be tortured 
 and destroyed ; and, combined as this attitude of 
 mind is with hallucination, it is apt to be confused 
 with paranoia, which it often closely resembles. It 
 is important to discriminate between the two, for 
 the insanity of alcohol is far more improvable than 
 paranoia, and the prognosis therefore much better, and 
 the treatment is different. The diagnosis is not usually 
 difficult, the defect of memory and the motor dis- 
 turbance of alcoholic insanity being sufficient, apart 
 from the history, to establish the difference. 
 
 The delusions are often those of pure suspicion and 
 persecution, such as have been instanced ; but there is 
 often a strain of vainglory and boastfulness running 
 through them in addition. The patient believes him- 
 self to be rich, to be a great personage, but at the same 
 time people are conspiring to rob him of his money or 
 his rank. He has not the confident security of the 
 ordinary megalomaniac, the general paralytic, or the 
 man with fixed delusion. 
 
 The disorder of memory is usually a prominent 
 feature in alcoholic insanity. There is usually marked 
 defect, and the defect is the same in character as the 
 defect in old age that is to say, the memory of long- 
 past events is tenacious and faithful, but the current 
 events of daily life are swept out of the memory as 
 soon as they have happened. The patient receives a 
 visit from his wife, who spends an hour with him, and 
 ten minutes after she has gone he has forgotten all 
 about the visit, and vows that she has not been near 
 him. He worries because he has not written a letter, 
 
VARIETIES-INSANITY FROM ALCOHOL. 161 
 
 which he has written and delivered to be posted a 
 dozen times or more. He has very little notion of the 
 lapse of time, and if he does remember a recent event, 
 he cannot tell whether it occurred to-day or yesterday, 
 or a week or a month ago. Together with this defect, 
 there is a peculiar delusion of memory which is not 
 so pronounced or so frequent in any other variety of 
 insanity. The patient remembers vividly and in detail 
 events which have never occurred at all. He will 
 describe visits that he thinks he has paid, will repeat 
 conversations that he believes he has taken part in, 
 scenes that he thinks that he has witnessed, none of 
 which have ever taken place at all. It sometimes 
 happens that the imaginary events which he describes, 
 and fully believes, that he has witnessed are assaults 
 upon himself or others, and he then becomes a 
 dangerous person. 
 
 Hallucinations occur more constantly in alcoholic 
 insanity than in any other variety of insanity except 
 paranoia. They are usually aural, sometimes visual, 
 and not infrequently affect the sense of smell or taste. 
 They are always unpleasant and disconcerting, and 
 usually work in with and corroborate the delusions of 
 suspicion. The evil taste or smell that he experiences 
 confirms his opinion of poison in his food. The voices 
 that he hears, the texts that he sees written upon the 
 walls, corroborate the suspicion of persecution to which 
 he is subject. 
 
 Of the motor disturbances, which are rarely absent 
 in alcoholic insanity, the chief is tremor, which is 
 usually pronounced. It occurs first and most in the 
 hands, but it subsequently affects the lips and articula- 
 tory organs generally. It is present both in rest and 
 during voluntary movement, but is more pronounced 
 
 .11 
 
162 TEXT-BOOK OF INSANITY. 
 
 in the latter. Following on tremor of the hands comes 
 a peculiar gait, which is neither a reel nor ataxy, but 
 a kind of stringhalt ; and the patient wavers in his 
 walk so that his course is not a straight line but an 
 irregular zig-zag. Cramp in the calf of the leg is 
 often frequent and severe in alcoholic insanity, and 
 occasionally convulsions occur in its course. Slight 
 irregularity of the pupils is not uncommon in alcoholic 
 insanity, as in many other morbid states, and the 
 reactions are apt to be sluggish, but they are never 
 absent. 
 
 Alcoholic insanity often simulates paranoia, from 
 which it may be distinguished as already described. 
 Its symptoms are often closely similar to those of 
 general paralysis, and there are cases in which the 
 diagnosis cannot be made, and we have to wait for the 
 course of the case to clear up the difficulty. The 
 history is not to be depended upon, for drunkards very 
 often deny their habit, and general paralytics have 
 often been intemperate. The tremor is closely alike 
 in the two cases. In the early stage of general 
 paralysis it is never so marked as it sometimes is in 
 the early stage of alcoholic insanity ; but sometimes 
 in the latter there is little or no tremor. If the peculiar 
 mnemonic delusions of alcoholism are present, their 
 presence is almost decisive, but the delusions of general 
 paralysis often approach them in character. The chief 
 reliance must be placed upon the pupillary reactions. 
 It has been said that these reactions are sometimes 
 lost in alcoholic insanity, but this is not my experience. 
 If either the reaction to light or that to accommoda- 
 tion is lost, or is seriously defective, then I believe that 
 general paralysis may be diagnosed without hesitation. 
 The difficulty is that in the early stage of general 
 
rrs 
 
 VARIETIES INSANITY FROM ALCOHOL. 163 
 
 paralysis there is sometimes no such sufficient defect 
 in these reactions as to enable us to make a diagnosis, 
 which must then remain in doubt. The importance of 
 clearing up the matter as soon as possible is very great, 
 for general paralysis is certainly fatal, while alcoholic 
 insanity is very improvable, and is compatible with 
 considerable duration of life. 
 
 In the treatment of alcoholic insanity, the first thing 
 to be done is to deprive the patient of his alcohol, and 
 this can only be done by sending him to an institution. 
 It is quite futile to attempt to treat such cases in their 
 own homes, for there they will always find means to 
 obtain their poison. It does not matter what vigilance 
 is exercised, they will endeavour to corrupt their nurses 
 or servants, and they will succeed at last. They are 
 sure to have a secret store bestowed somewhere about 
 the house to which they will get access at times. The 
 only possible chance of completely depriving them is 
 to place them in a lunatic asylum. The first week 
 of their deprivation will be a terrible time for them. 
 They will suffer agonies of depression and misery, will 
 become perhaps riotously maniacal, and will give endless 
 trouble by their false accusations and general perversity. 
 The alcohol need not be absolutely withheld. Sleep is 
 often better obtained if a dose of whiskey in hot milk 
 is given at night ; and when the misery becomes very 
 great, the same remedy will give relief. So long as 
 the patient is in the institution, we have him under 
 absolute control, and we need not fear the result of an 
 occasional dose of stimulant. He probably suffers from 
 gastritis, more or less, and this must be treated, 
 especially as it is important in this, as in acute insanity, 
 to feed copiously. Iron and bitter tonics will be found 
 useful, but the chief reliance is to be placed upon 
 
164 TEXT-BOOK OF INSANITY. 
 
 deprivation of alcohol, copious feeding, regular hours, 
 and fresh air. In these circumstances the improvement 
 that takes place is often surprising. The patient in 
 a few months becomes so well that it is very difficult 
 to detain him in an institution ; and, yet, if he is dis- 
 charged, he will certainly return to his drinking habits 
 and relapse. 
 
 12. GENERAL PARALYSIS. 
 
 There is no variety of insanity more distinct or more 
 important than this. It is so distinct that some years 
 ago a very able writer on insanity divided this malady 
 into two varieties only ordinary insanity and general 
 paralysis. Its importance lies in its frequency, in its 
 progressive and incurable character, and in the frequent 
 difficulty of its diagnosis. 
 
 In the main, general paralysis is a disease of middle 
 life and of the male sex. It seems to affect by preference 
 vigorous, energetic, successful men, who have lived full, 
 active, busy lives in cities ; who are married ; who 
 have indulged freely in eating and drinking, and in 
 sexuality; and in whom an hereditary disposition to 
 insanity is absent. While this is the character of the 
 majority of persons who become the victims of general 
 paralysis, the malady is not strictly limited to such 
 persons. It does occur also in those who have an 
 insane inheritance, and about 10 per cent, of general 
 paralytics are thus characterised. It does occur also 
 in women, about 19 per cent, of the occurring cases 
 affecting this sex ; and in rare cases it occurs in early 
 life, in children in the early teens, and then it is 
 invariably found to be associated with hereditary 
 syphilis. So singular and invariable an association in 
 
VARIETIES GENERAL PARALYSIS. 165 
 
 these early cases led to strict inquiry with respect to 
 the antecedents of general paralytics of mature age, 
 and it was then found that in a very large proportion 
 of these also syphilis was antecedent to the disease. 
 It was found that in 80 per cent, there was absolute 
 proof of syphilis, either in the history or in stigmata 
 existing in the body. In the remaining 20 per cent, 
 no history or sign of syphilis could be found, but then 
 it is found that with respect to other lesions which are 
 unquestionably syphilitic, but which occur long after 
 the infection, there is a residue of 20 per cent, in 
 which no history of syphilis and no other stigmata of 
 syphilis exist. We are therefore driven to the conclu- 
 sion that syphilis is a very constant if not an invariable 
 antecedent of general paralysis, and certainly the most 
 important factor in the causation of the disease. 
 
 It is certainly not the sole factor, however. Only a 
 very small proportion of the persons who are syphilitic 
 become general paralytics ; and in almost all cases of 
 general paralysis we find that the patient has recently 
 passed through a period of mental or other stress, 
 which has seemed to determine the onset of the disease. 
 He has had great anxiety in his business or in his 
 family ; he has indulged too freely in alcohol ; he has 
 had influenza ; he has had a blow on the head ; or he 
 has suffered from some other form of stress; and it 
 seems that it is this provocative occasion, acting upon 
 a person already syphilised, that determines the disease. 
 It is to be remembered that general paralysis is closely 
 allied to tabes; that tabes sometimes culminates and 
 terminates in general paralysis ; that true tabetic 
 symptoms occur in general paralysis ; and that the 
 affections of the oculo-motor apparatus in the two 
 diseases are closely allied. Hence we have additional 
 
166 TEXT BOOK OF INSANITY. 
 
 reason for expecting that the causes that produce the 
 one will be closely similar to those that produce 
 the other. 
 
 General paralysis may begin quite suddenly, with 
 a fit, or with an outbreak of acute insanity of which no 
 warning has been given ; but usually, after the disease 
 has declared itself, it is remembered that for days, 
 w<vks, or perhaps even months, the patient had been 
 failing in certain assignable ways. It is rare, however, 
 for these warnings to be sufficiently pronounced and 
 sufficiently definite to enable us to predict, or even to 
 suspect, what is corning. When it is not sudden, the 
 onset of the disease is usually rapid. 
 
 The prodromata may be divided into four groups, 
 and are, in the order of their frequency, moral, in- 
 tellectual, sensory, and motor. 
 
 The most frequent of the early changes of general 
 paralysis is a change and a degradation of the moral 
 tone of the individual. His character changes. Always 
 a busy, energetic man, prone to take risks, to keep late 
 hours, to live freely, all these characteristics become 
 accentuated. His energy becomes overpowering ; he 
 undertakes more than he can get through, and his 
 affairs become more and more involved and entangled ; 
 he speculates more rashly ; he goes about more ; he 
 takes long journeys upon slight inducement; he drinks 
 more; he is less particular about his associates and 
 companions; he goes among loose women; he talks 
 too much, and chatters among strangers about his 
 private affairs ; he becomes effusive ; he gives presents 
 without sufficient justification ; he brags. He is like 
 a man always a little under the influence of drink ; 
 and, as he does drink a good deal, his peculiarities are 
 attributed to drink alone. When this phase of conduct 
 
VARIETIES-GENERAL PARALYSIS. 167 
 
 is but slightly marked, it may be considered as a 
 prodroma of the disease, but when it is exaggerated, 
 it constitutes the first stage of the malady in one of 
 its forms. 
 
 The prodromata on the intellectual side, in addition 
 to those included in the above description, consist of a 
 want of mental efficiency, more or less marked, and 
 existing for a longer or shorter time before the outbreak 
 of the disease. The patient becomes stupid. He 
 cannot concentrate his attention ; he forgets things ; 
 he makes mistakes ; he is confused in his mind, 
 and it is apparent that he is less capable in business 
 and less able to transact all the affairs of life than he 
 was. When these symptoms are but slight, they are 
 looked on as prodromata. When pronounced, they 
 constitute the demented form of the disease. 
 
 Neither the pupillary abnormalities nor the articu- 
 latory troubles, however slight in degree, are counted 
 among the prodromata of general paralysis. If they 
 exist at all, we regard the disease as established ; but 
 then the pupillary changes are not seen until they are 
 looked for, and they are not looked for until some more 
 prominent symptom suggests general paralysis. The 
 articulatory defect, again, is never a very early symptom. 
 Often the patient has been consigned to an asylum for 
 months before the defect of articulation shows itself, 
 and it never appears before the mental symptoms. 
 But before the definite outbreak of the disease there 
 may be transient motor troubles. A limb may become 
 weak, or an eyelid may droop, or there may be transient 
 aphasia or transient strabismus, which, with a history 
 of syphilis, may give rise to a suspicion of gumma. 
 The handwriting sometimes becomes sprawling or 
 shaky, but it does not, in this early stage, show the 
 
168 TEXT-BOOK OF INSANITY. 
 
 characteristic changes that will be presently described. 
 In those cases in which the morbid change first attacks 
 the cord, ataxy of the gait may properly be looked 
 upon as a prodroma of general paralysis ; but until the 
 insanity declares itself, there is nothing to distinguish 
 such cases from ordinary tabes. In rare cases there 
 may, in the early stage, be a transient ataxy of gait, 
 comparable with the transient aphasia ; or there may 
 be attacks of giddiness, faintings, or purposeless vomit- 
 ing. It will be seen from this description that although, 
 when the disease declares itself, we can recognise that 
 such motor symptoms as these were its earliest mani- 
 festations, yet, until the malady is otherwise recognis- 
 able, there is nothing in them to point to an oncoming 
 general paralysis, or to lead us to anticipate its oc- 
 currence. 
 
 On the sensory side, the warnings, if warnings they 
 can be called, are similarly transient, similarly isolated, 
 and usually similarly sudden. When a patient is 
 brought to us with definite general paralysis, we may 
 learn that during the previous twelve or eighteen 
 months he has been treated for a sudden deafness of 
 one ear, or blindness of one eye, or for neuralgia, or 
 severe headache, or for local numbness or anaesthesia ; 
 but it is not possible, at the time these symptoms 
 occur, to predict that they will be followed by general 
 paralysis. 
 
 The onset of the disease may be sudden, and is 
 usually rapid. Often it is possible to assign the very 
 day upon which the malady declared itself, either by 
 a fit of some kind, or by an outbreak of acute mania. 
 Often the symptoms, which have been described as 
 moral or intellectual prodromata, become rapidly 
 exaggerated in intensity until, in the course of a week 
 
VARIETIES GENERAL PARALYSIS. 169 
 
 or so, the apprehension that the patient may be going 
 out of his mind becomes a fact only too patent. In 
 any case, the definite invasion of the disease is usually 
 an attack of acute insanity, and in the majority of 
 cases the acute insanity is of the maniacal type. In 
 a minority of cases the acute insanity of the onset is 
 melancholic or resistive. It is scarcely ever suicidal. 
 It is usually very acute, and marked by aggression 
 and violence. Sometimes it is so acute as to be taken 
 for acute delirious mania. It lasts for a few days, or 
 more often for several weeks, and then subsides into a 
 sub-acute insanity which exhibits one of the following 
 types : 
 
 1. The maniacal or classical type. 
 
 2. The melancholic type. 
 
 3. The demented type. 
 
 4. The fulminating type. 
 
 5. The circular type. 
 
 6. The spinal or tabetic type. 
 
 1. The maniacal or classical type of general paralysis 
 is the most distinctive and most striking of all forms 
 of insanity. In no other form do we witness such 
 exaggerated hyperbolical exaltation. The patient owns 
 millions and millions ; he is thousands of years old ; he 
 has hundreds of wives, thousands of children ; he has 
 such titles as were never heard of ; he is the greatest 
 inventor, artist, poet, warrior, statesman, pitch-and-toss 
 player, the world has ever seen. He is lavishly 
 benevolent ; he will give cheques for millions, written 
 on dirty bits of newspaper, to all bystanders. He talks 
 incessantly, save when he is writing; and he writes 
 incessantly, save when he is talking. He corresponds, 
 still on margins of newspapers, or dirty scraps picked 
 
170 TEXT-BOOK OF INSANITY. 
 
 up in the road, with all the crowned heads of Europe 
 and all the celebrated people he can think of. His 
 writing is characteristic. It is sprawling and shaky ; 
 it is unrecognisable as his ordinary handwriting. He 
 omits letters; he fails to finish his words; he omits 
 syllables, and often whole words. He runs the words 
 together in writing just as he does in speech, and often 
 he repeats the same word twice or oftener. 
 
 In this stage he sleeps little, he is up early and 
 late, he is full of eager, busy, futile activity. In 
 whatever is going on he must take part, and principal 
 part. If anything is being discussed, he lays down the 
 law ; if anything is being done, he takes the command. 
 He appropriates everything he has a mind to, and 
 when his pockets are turned out, they are found to 
 contain as miscellaneous a collection as a magpie's nest 
 other people's pipes, handkerchiefs, and pencils, one or 
 two playing-cards, bits of string, bits of bread, sticks, 
 stones, dead leaves, and bits of paper innumerable. 
 
 At the same time, with all his grandeur and majesty, 
 he is singularly weak of will and easily influenced. 
 In his own house he is obedient to his own servants, 
 if they are at once authoritative and judicious. He 
 does what he is told. He is full of preposterous 
 schemes, but he is diverted from their pursuit with 
 the utmost ease ; and even if left alone, he does not 
 pursue any one of them for more than a few moments 
 together. He is subject to outbursts of temper, rising 
 often to fury, but they are shortlived and easy to con- 
 trol. Sent to an asylum, he accepts the situation 
 without murmur and without question. He does not 
 resent his removal from home ; he sees nothing worthy 
 of protest or remark in the control to which he is 
 subjected. 
 
VARIETIES -GENERAL PAKA LYSIS. 171 
 
 In this excited and grandiose condition he remains 
 for a few months, becoming gradually calmer and more 
 demented, until at the end of a variable time, usually 
 about a year after the onset of the disease, he has a fit, 
 and then the course of the disease follows the order that 
 will be presently described. 
 
 2. The demented type. In common with other 
 insane persons, all general paralytics are demented in 
 every stage of their malady ; but what is meant by 
 the demented type of general paralysis is a form 
 of the disease in which the dementia is simple, 
 and is unaccompanied by the active symptoms so 
 characteristic of the other forms. In the second stage 
 of the disease that is to say, after the first fit 
 the more active symptoms subside in every type 
 of the disease, and the case approaches to one of 
 simple dementia ; but in the type now under con- 
 sideration the symptoms are never very active. The 
 patient is from the first heavy, stupid, lethargic, 
 inactive ; whatever activity there is in the mind is of 
 the same cast as in the classical type, and the patient 
 often surprises us by evincing out of his dulness 
 some extravagant delusion ; and just as in the other 
 types, the period of simple dementia sets in with 
 the fits, so in this type fits occur early in the course 
 of the malady and are frequent daring its progress. 
 This is the form that general paralysis usually takes 
 when it begins with a fit. As might be expected, 
 the course of the disease is more rapid than in the 
 classical type. 
 
 3. The melancholic type. General paralysis usually 
 begins with an attack of acute insanity, and, as already 
 stated, the acute insanity of the commencement is 
 sometimes melancholic or resistive in type. When this 
 
172 TEXT-BOOK OF INSANITY. 
 
 is so, the tinge of melancholia usually remains through- 
 out the progress of the disease. Not infrequently a 
 case that has, begun with acute mania becomes sub- 
 sequently melancholic. The patient then presents 
 the physical signs of general paralysis together with the 
 ordinary mental symptoms of melancholia. But the 
 melancholic symptoms are not quite ordinary ; they are 
 often combined with an element of grandiosity in excess 
 of what is seen in ordinary melancholia. The ordinary 
 melancholic believes that his bowels are obstructed, 
 and that he has had no motion for a month ; the melan- 
 choly general paralytic has had no motion for thirty 
 years. The ordinary melancholic has a ton weight 
 resting on his body ; the melancholy general paralytic 
 is crushed under the weight of the whole earth. The 
 melancholia of general paralysis may be ordinary 
 delusional melancholia or may be of the resistive 
 type. It may be associated with stupor, and it may 
 be attended with suicidal attempts, though these latter 
 are not common in general paralysis. In the melan- 
 cholic form .there are not the remissions and periods 
 of improvements that take place in the classical form, 
 or if they occur, they are much less marked. 
 
 4. General paralysis of fulminating type is a terrible 
 malady. Whereas the other types of the disease begin 
 with acute insanity, this type begins with the acutest 
 form of insanity acute delirious mania. Whereas the 
 other types pass through the various stages in the 
 course of two or three years ere they terminate in 
 death from exhaustion, the fulminating cases run 
 their course in six months, in four or three months, 
 or even less. The symptoms are those of the classical 
 form, but they are much more acute, and the course 
 of the disease is very much more rapid. 
 
VARIETIES GENERAL PARALYSIS. 173 
 
 5. The circular type of general paralysis is rare. 
 It begins in the ordinary way with an outbreak of 
 sub-acute, culminating in acute, insanity, with the 
 exaltation, braggadocio, extravagance, and immorality 
 of the classical form. After a few months, the acute 
 symptoms subside, as they usually do in the classical 
 form ; but instead of the relapse that takes place in 
 the other types of general paralysis, the patient con- 
 tinues to improve until he is practically well, and it is 
 thought that the diagnosis was wrong, and that the case 
 was not one of general paralysis at all. After a few 
 months of sanity, the patient begins to be depressed, 
 and gradually sinks into profound melancholia, for 
 which he is again sent to an asylum, and from which 
 he again recovers and returns to active life. Then, 
 after an interval, occurs a new outbreak of acute mania, 
 and the circle is complete. The circle may be renewed 
 more than once before the physical signs exhibit them- 
 selves, and the case then follows the usual course of the 
 classical type of general paralysis. 
 
 6. The spinal type. General paralysis always in- 
 volves the spinal cord sooner or later ; spinal paralyses 
 are present during life, and spinal cord degeneration 
 is found after death. In the ordinary types, the brain 
 is affected first and most ; and symptoms due to disease 
 of the spinal cord appear late in the course of the 
 disease, when the patient is already a wreck, and 
 consequently do not attract much attention. But 
 there are cases in which the spinal cord is first 
 attacked, and the malady begins as tabes or as 
 spastic paraplegia, upon which the mental and other 
 symptoms of general paralysis are subsequently 
 grafted. 
 
 In addition to the six forms described, general 
 
174 TEXT-BOOK OF INSANITY. 
 
 paralysis exhibits certain peculiarities when it occurs 
 in women and in the young. 
 
 The disease is less frequent in women than in men, 
 in the proportion of less than one to five. The 
 symptoms in women are less aggravated, less pro- 
 nounced. All the manifestations are milder. The 
 type is usually the demented, but unlike the demented 
 type in men, the course of the malady is prolonged. 
 It is more " chronic " in character than it is in men. It 
 usually sets in earlier in life nearer thirty than forty, 
 and the physical symptoms are less pronounced. 
 The tremor, the articulatory defect, the involvement 
 of pupils, appear later and are less pronounced, and 
 fits are less frequent. 
 
 In children also, the s} 7 mptoms and the course of the 
 disease are sub-acute, and the general character of 
 the malady is similar to that in women. It is always 
 associated with hereditary syphilis. 
 
 Physical signs. These are of extreme importance, 
 for until they are recognised the diagnosis cannot 
 be made. The earliest are the pupillary changes. 
 Next come defects in articulation ; then the manual 
 movements, and especially the handwriting, are 
 affected ; and lastly the gait deteriorates. This is 
 the usual course, but, as already noted, there are cases 
 in which tabetic symptoms precede the mental changes 
 by months or even years. 
 
 The pupils are usually unequal, and often deviate 
 from circularity and become oval or irregular in 
 outline, and they fail to react to light, or in accommo- 
 dation, or both. In ninety-nine cases out of a hundred, 
 when unresponsive pupils co-exist with any form of 
 mental disorder, the case is one of general paralysis. 
 As far as my experience goes, the pupillary symptoms 
 
VARIETIES-GENERAL PARALYSIS. 175 
 
 are not only the earliest of the physical signs, but 
 they are never absent in commencing general paralysis. 
 Hence their extreme importance. 
 
 The articulatory defect comes later, and is highly 
 characteristic. It is exactly the same as that of a 
 drunken man. The speech is " thick." The words 
 are clipped and run together. The patient often 
 speaks with extreme deliberation, so as to overcome 
 the defect, of which he is conscious ; but if he speaks 
 at all quickly, the words are blurred and fused together, 
 and syllables are omitted. The labials and dentals are 
 first affected; and when the disease is further advanced, 
 the voice itself becomes involved and assumes a very 
 characteristic peculiarity. It becomes monotonous. 
 Cadence is lost ; and in addition there is often a 
 peculiar bleat, which can always be recognised after 
 it has once been heard. 
 
 The face is remarkably expressionless. It looks 
 puffy, and the normal lines and folds fill up and 
 disappear. The cheeks and alee nasi are often slimy 
 with grease, and when the patient speaks, there is 
 tremor, not only of the lips and of the tongue, but 
 of the muscles of the cheeks as well. 
 
 The peculiarities of the handwriting have already 
 been described. Other movements of the hands are 
 often defective. The patient has difficulty with his 
 buttons, and cannot pick up a pin from a smooth 
 surface. 
 
 The gait does not become defective until the later 
 stages of the disease, and then the defect is not very 
 definite. It is not ataxic ; it is not a reel ; it is a 
 general inefficiency which is scarcely describable other- 
 wise. The patient walks slowly, turns with difficulty, 
 and is apt to fall ; but there is no localised or 
 
176 TEXT-BOOK OF INSANITY. 
 
 differential paralysis. It is a generally diffused weak- 
 ness and incompetency. 
 
 The knee-jerks are usually exaggerated in the early 
 stage of the malady. Subsequently they may disappear 
 and reappear, and may be different in the two sides. 
 
 Stages and Fits. General paralysis is a progressive 
 disease, and it is usually described as marked off into 
 three stages, the first extending from the outbreak of 
 the disease until the first fit; the second from the 
 first fit till the patient becomes bedridden ; and the 
 third the bedridden stage. It is not always possible 
 to mark these distinctions, nor are they very important. 
 But the occurrence of the fits is a very important 
 incident in the progress of the malady. 
 
 As already stated, the disease may begin with a 
 fit; and whether it does so or no, fits, or sudden 
 exacerbations allied to fits, invariably occur in the 
 course of the disease, usually beginning about midway 
 in its duration. In different cases the fits are very 
 different in character, but in the same case the fits 
 usually are closely alike. In the classical type of the 
 disease, the fit is a universal convulsion, indistinguish- 
 able from those of epilepsy. It begins less suddenly, 
 it is true, than epileptic paroxysms usually begin, but 
 in other features it is the same. The head and eyes 
 deviate to one side, the spasm becomes universal, 
 may be accompanied by evacuation of the bowels and 
 bladder, and is followed by a period of coma. Fits of 
 this kind may succeed one another rapidly, so that 
 the patient passes into the status epilepticus, which 
 is far more common in general paralysis than in 
 idiopathic epilepsy; and in this condition a certain 
 proportion of general paralytics die. 
 
 Very commonly the fit is not of this definite 
 
VARIETIES-GENERAL PARALYSIS. 177 
 
 character. Often it is " apoplectiform," but, in this 
 case again, it rarely has the very rapid onset of 
 hsemorrhagic apoplexy. The patient becomes duller 
 and duller, more and more stupid, until in the course 
 of an hour, or two or three hours, he is comatose. 
 The coma is not usually deep rarely so deep as to be 
 stertorous and often it is found to be combined with 
 rigid deviation of head and eyes to one side, so that 
 it partakes of the nature of epilepsy. 
 
 In very many cases, the character of the fit is less 
 definite than this. There is no convulsion, nor is 
 there actual coma, but the patient becomes for a few 
 hours unusually dull, lethargic, and stupid. He lies 
 about; he does not answer, or he answers slowly and 
 at random ; he cannot be got to take his food ; he 
 seems dazed ; he is muscularly weak and incapable of 
 exertion ; and when this condition passes off, he is 
 found to have undergone the deterioration which, as 
 will be presently noticed, invariably follows the fits of 
 general paralysis. These attacks are sometimes called 
 " congestive " it is hard to say why. 
 
 At the stage of the disease at which fits are 
 customary, there sometimes occur causeless attacks 
 of bilious vomiting, or of profuse diarrhoea, which are 
 sometimes followed by fits, and sometimes seem to 
 take the place of fits, or to be a variety of them. In 
 yet other cases, the fit is replaced by a local paralysis, 
 or by a general loss of power, which, by its sudden or 
 rapid onset and its gradual recovery, exhibits its 
 community of nature with the more easily recognised 
 fit. 
 
 It is sometimes said that fits do not occur in all 
 cases of general paralysis, and if by a fit is meant an 
 epileptoid or apoplectiform seizure, this is true ; but 
 
 12 
 
178 TEXT-BOOK OF INSANITY. 
 
 I have never seen a case of general paralysis in which 
 periodical crises of some kind have not occurred ; and 
 if we include, as I think we should, all periodical 
 crises of every kind under the term " fit," then I 
 think there is no case of general paralysis in which 
 fits do not occur. 
 
 Whatever the nature of the crisis or fit, it has a 
 very marked effect upon the condition of the patient. 
 When he emerges from it, he is found to be greatly 
 deteriorated. His delusions are, perhaps, less prominent, 
 but this is because he is too stupid to entertain them. 
 He is much weaker in body, and he is much more 
 demented in mind. As the days and weeks pass by, 
 he gradually improves. He climbs the hill again ; he 
 recovers a great part of his mental and bodily aptitude, 
 but invariably, before he has completely regained the 
 ground that he lost by the fit, he has another fit ; 
 and when he emerges from this, he is found to be on 
 a lower level of capacity, both bodily and mental, than 
 he was after the previous fit. Agains he climbs the 
 hill. Again, after the lapse of weeks, or it may even 
 be months, he regains a great deal of his lost ground, 
 but he never regains it all. Invariably, before he has 
 attained to the condition that he reached after the 
 first fit, a third occurs, which reduces him to a still 
 lower depth, and so the malady progresses, each fit 
 leaving behind it a greater wreck, from which recovery 
 is less complete. 
 
 This effect of the fits upon the course of the disease 
 is an instance of the periodicity which is discernible 
 more or less distinctly in the course of every case of 
 general paralysis. General paralysis has been called 
 progressive paralysis, but its course is never continuously 
 progressive. While its general course is steadily down- 
 
VABIETIES GENERAL PARALYSIS. 179 
 
 ward if sufficient intervals are taken, yet, when minutely 
 examined, it is found that this downward progress is 
 not continuous, but is always remittent, a rapid or 
 sudden decline being followed by gradual improve- 
 ment, and this alternation being continued throughout 
 the disease. This character is discernible from the 
 very first. The outbreak of the malady is, as we 
 have seen, sudden or very rapid, and is followed by 
 a gradual recovery, which may be so complete that 
 the patient is able to return to his business, and 
 to resume his place in the world for several months ; 
 and this is called a complete remission. But when 
 careful observation is made, it is found that the 
 remission is not complete, but that it conforms to 
 the rule by which the recovery from every crisis 
 culminates in a state, which is never so near a 
 return to the normal as the pre-critical state. In 
 these " complete remissions " it is found that the 
 character of the patient i? a good deal deteriorated, 
 and that his intelligence is less keen. He goes back 
 to his work and his family, it is true, but he can no 
 longer do his work capably, and his family remarks 
 a decided change in his disposition. Thus the circular 
 type of general paralysis is no departure from the 
 type of the malady, but merely an exaggeration of a 
 feature which all cases present in some degee. 
 
 With each recurrence of the crisis, the patient 
 becomes more and more demented, and more and 
 more paralytic. At length he becomes incapable even 
 of sitting up, and is confined entirely to bed ; and at 
 the same time the lapses of the control of his bladder 
 and bowels, which have been occasional since the crises 
 began, now become habitual. The patient ceases to have 
 the character of an intelligent being. He lies in bed 
 
180 TEXT-BOOK OF INSANITY 
 
 in the extreme stage of dementia, his arms crossed, his 
 legs drawn up, all his limbs gradually becoming more 
 and more rigidly contracted. He passes his urine and 
 motions under him. He is incapable of conveying food 
 to his mouth or of brushing away the flies that crawl 
 over his face and into his open mouth. It is with the 
 greatest difficulty that he is saved from getting bed- 
 sores, and at length he dies, either in a fit, or in coma, 
 or from diarrhoea, or pneumonia, or some other disease 
 of exhaustion. This bedridden condition is called the 
 third stage of the disease. 
 
 The general bodily condition presents characteristic 
 peculiarities in the three stages of the disease. In 
 the first, the maniacal stage, the patiently is usually 
 remarkably ''fit." He is in fine "condition." He 
 is muscularly strong, and he is wanting in super- 
 fluous fat. His condition is much as if he had been 
 well trained for some athletic contest. In the second 
 stage, as he becomes stupid he gets fat. The lines on 
 his face fill out and are obliterated, and his face becomes 
 more greasy, pulpy-looking, and expressionless. In the 
 last stage, he emaciates, and the emaciation is often 
 extreme. 
 
 A very remarkable and very unfortunate nutritive 
 anomaly, that may take place at any time after the 
 first stage of general paralysis, is a change in the 
 structure of the bones, by which they become un- 
 usually, and in some cases surprisingly, brittle. This 
 change is so great in some cases that a rib can be 
 easily broken with a thumb and finger, and as general 
 paralytics become very helpless, and often at the same 
 time very restless and apt to fall about, the brittleness 
 of the bones becomes a source of great danger. A 
 certain number of general paralytics die every year 
 
VARIETIES-GENERAL PARALYSIS. 181 
 
 from pneumonia following fractured ribs, or from shock 
 and exhaustion following fracture of other bones. 
 
 Diagnosis. When once the physical signs are 
 decided, there is no difficulty whatever in diagnosing 
 general paralysis. The defect of articulation is pathog- 
 nomonic, and the pupillary signs, when conjoined with 
 mental disorder of any kind, are equally so. But before 
 the physical signs are established, the difficulty of 
 deciding whether a case is or is not one of general 
 paralysis may be very great may, indeed, be insuper- 
 able. Cases not seldom occur in which a diagnosis is 
 for the time impossible, and we must wait the further 
 development of the disease before giving an opinion. 
 
 Generally, any rapid or sudden outbreak of insanity, 
 of any form, in a middle-aged man, in whose family 
 there is no history of insanity, should put us on our 
 guard, and lead us to suspect general paralysis. Even 
 a definite family history of insanity does not exclude 
 general paralysis, but it is much more frequent in men 
 with a sound family constitution. General paralysis 
 sometimes begins with a fit, and the fits are very varied 
 in character ; hence, any cerebral crisis, for which no 
 adequate cause can be found, should raise a suspicion 
 of general paralysis when it occurs in middle age. 
 
 Acute mania with grandiose delusions and the 
 scattering of cheques for millions, even when occurring 
 in a man of middle age and a fast liver, does not 
 always mean general paralysis. It may be simple 
 acute insanity and may recover. But if any of the 
 physical signs of general paralysis are present, the 
 diagnosis is no longer in doubt. 
 
 Dr. Savage lays stress upon the gain of weight in 
 the melancholy type of general paralysis, as against 
 the loss of weight or the continued meagreness of the 
 
189 TEXT-BOOK OF INSANITY. 
 
 ordinary melancholic. This gain of weight is a very 
 important sign if the pupillary and articnlatory defects 
 are absent, but usually, by the time the patient has 
 entered upon the fattening stage, these motor defects 
 are already conspicuous. 
 
 The greatest difficulty in the diagnosis of general 
 paralysis is in deciding, in a doubtful case with a 
 history of alcoholic excess, whether the disease is 
 general paralysis or alcoholic insanity. The difficulty 
 is the greater, since general paralytics often take to 
 drink in the early stage of the malady, and often have 
 habitually indulged too freely ; and it is the greater 
 since alcohol itself produces motor disorder allied to 
 that of general paralysis. The main reliance must be 
 placed on the pupillary changes. These are not present 
 in alcoholic insanity, but they may be absent also in 
 the early stage of general paralysis. The history of 
 morning vomiting is important. There are only two 
 conditions with which regular morning vomiting is 
 associated pregnancy and alcoholism. But we must 
 be careful to ascertain that the vomiting is regular, 
 and is not a sporadic crisis. The general paralytic 
 sleeps well, though his sleep is short ; the alcoholic 
 patient sleeps badly, and is apt to suffer from terrifying 
 dreams. The memory does not present in general 
 paralysis the characteristic defect in recent matters 
 that is so conspicuous in alcholism. The defect of 
 gait and the tremor of hands in the two maladies 
 may be closely alike, and in alcoholism the articulation 
 may be defective, but the defect is not of the same 
 character. 
 
 Prognosis. General paralj 7 sis is always fatal, and 
 usually is rapidly incapacitating. Cases are not very 
 uncommon, however, in which, after the acute attack 
 
VARIETIES-GENERAL PARALYSE 183 
 
 of insanity which marks the onset of the disease, the 
 patient recovers sufficiently to return to his family and 
 his business for three, six, or twelve months, or even 
 longer. Sooner or later, however, the malady recurs, and 
 although it always runs a remittent course, it is very rare 
 for a second remission to be so complete as to allow of 
 a return home. The average course of the disease 
 is about three years, but it is often less than this, 
 and occasionally it is prolonged for four or five years. 
 The circular type is that of longest duration. 
 
 Treatment. There is at present no curative treat- 
 ment of general paralysis. Seeing how intimately 
 it is associated with syphilis, it is natural that anti- 
 syphilitic remedies should have been extensively tried, 
 but they have never been found of the least use. 
 Removal to an institution is always necessary. In no 
 class of cases do we witness outbreaks of such frantic 
 violence as in general paralysis, and, as they take place 
 without any warning, and in cases that have previously 
 been quiet and tractable, it is essential that the patient 
 should be in a place where a sufficient staff is available 
 at a moment's notice to deal with him in his outbreak. 
 For the rest, treatment must be of symptoms, and it 
 is important to remember that general paralytics are 
 very amenable to the action of drugs, and that their 
 allowance of tobacco should be very limited, for it is 
 very apt to prostrate them. Sulphonal is the best 
 calmative of excitement, and paraldehyde the best 
 hypnotic ; but the former easily produces a great 
 effect upon the gait by its paretic effect on the muscles. 
 Trephining has been tried, to diminish an imaginary 
 intra-cranial pressure, but without any beneficial effect ; 
 and the same may be said of paracentesis of the spinal 
 canal. Blistering of the scalp and setons have been 
 
184 TEXT-BOOK OF INSANITY. 
 
 tried, but no would-be curative treatment is of any 
 avail. In the second stage of the disease the patient 
 becomes extremely voracious, and is apt to choke 
 himself if allowed to feed himself. His food must 
 be cut up, and no implement larger than a teaspoon 
 allowed, and if necessary he must be fed. The brittle- 
 ness of the bones is a source of great anxiety ; and 
 every care must be taken to prevent the patient falling 
 about, or getting into quarrels with other patients. In 
 the final stage, the prevention of bedsores must be 
 managed secundem artem, and the status epilepticus 
 treated in the usual way with rectal injections of 
 chloral. 
 
 The Pathological Anatomy of general paralysis is 
 very characteristic. There is, it is true, no single 
 change which may not be found in other maladies, 
 but there is no other malady in which the same 
 combination of changes is found. 
 
 The skull is usually thick and heavy ; the dura 
 mater, too, is usually thickened and adherent to the 
 skull. Sometimes a meningeal hsemorrhage, or the 
 remains of such a hemorrhage, in the shape of cyst 
 or membrane, is found between the dura and the 
 arachnoid. The brain is manifestly shrunken, and 
 in consequence the sub-dural and sub-arachnoid fluid 
 is copious, so that the arachnoid and pia have a 
 thickened, semi-opaque, jelly-like appearance. When 
 the membrane is stripped off, it is found to be strongly 
 adherent along the summits of the convolutions of the 
 frontal lobe, so that in these positions a portion of the 
 brain substance is torn off along with the membrane, 
 and a streak is left in the middle of the gyrus, in 
 which the brain appears as if it had been nibbled by 
 a mouse. 
 
VARIETIES-GENERAL PARALYSIS. 185 
 
 The brain is shrunken in all its dimensions ; the gyri 
 are thin and the sulci wide, this change being most 
 conspicuous in the frontal lobe, and diminishing 
 backwards. The ventricles are large, and the basal 
 ganglia small, and foci of softening are common in 
 various parts of the brain. Histologically, the nerve 
 elements are diminished and the connective tissue is 
 increased, but, as is evident from the general atrophy, 
 the former process is greatly in excess of the latter. 
 Both cells and nerve fibres suffer, and suffer together, 
 and the morbid change has the characters, in as far 
 as tfiey are distinct, of primary rather than of secondary 
 degeneration. The cells lose the definition of their 
 outline, and not only of their external contour, but 
 of their internal organisation also. The Mssl bodies 
 break up (chromatolysis), the nucleus becomes indistinct, 
 its outline is lost, and at length it disappears. The 
 cell loses its shape, and approaches more and more to 
 tne shape of a sphere, by an apparent retraction of the 
 substance that is prolonged into the fibres, and by the 
 bulging of the contour between the origin of the fibres. 
 At first increased in size, in later stages it shrinks, 
 breaks up and disappears, leaving a pigrnented detritus 
 which is subsequently absorbed. The processes partake 
 in the destruction of the cells. As the cell-body alters 
 in form, the processes, from being manifest prolonga- 
 tions of the substance of the cell, appear as if stuck 
 into it, or to project from it like the root of a turnip. 
 The finer ramifications disappear, the main processes 
 shrink, dwindle, break up first into lengths and then 
 into granules, which are absorbed and disappear. The 
 same process affects the association and other fibres. 
 
 The connective tissue element in the brain shows 
 great relative increase, owing to the disappearance of 
 
186 TEXT-BOOK OF INSANITY 
 
 so much of the nerve tissue proper. Whether it is 
 upon the whole increased in bulk is doubtful, but 
 certain of its constituents are undoubtedly larger, 
 more prominent, and relatively, if not absolutely, 
 more numerous. The glia takes the stain more 
 deeply than in the normal brain, and as the cells 
 are smaller and wider apart, from the absorption of 
 so many, it constitutes, in any one section, a much 
 larger proportion of the field. The glia cells appear 
 to be more numerous, they are more deeply stained, 
 they are larger, and their visible processes are more 
 numerous and more pronounced. Where the nerve 
 cells are most affected, the spider cells are very 
 numerous, and exhibit a large and well-marked pro- 
 cess passing to the wall of the nearest vessel, where 
 it ends in a plate of nucleated protoplasm. A number 
 of other processes surround and envelop the degener- 
 ating nerve cell. As the nerve cell disappears, the 
 body of the spider cell shrinks, and what remains of 
 it at last is a network of fibrils. 
 
 The blood vessels are numerous, large, tortuous, and 
 dilated at intervals along their course. Their coats 
 are thickened, the endothelial nuclei are increased in 
 number, and around the vessel are groups of extra va- 
 sated leucocytes mingled with haematoidin crystals. 
 The wall of the vessel exhibits hyaline or fatty change, 
 the perivascular lymph spaces are large, and contain 
 masses of lymph-corpuscles here and there. 
 
 In the pia-arachnoid the vessels are unusually 
 numerous and prominent, and the whole of the con- 
 nective tissue apparently increased in amount, and 
 permeated throughout with exudation and with nuclei. 
 
 In a large proportion of cases changes are found 
 in the spinal cord similar to those in the brain. The 
 
VARIETIES-INSANITY OF EPILEPSY. 187 
 
 theca is similarly thickened and adherent, with evi- 
 dence of blood extravasation within it, and occasionally 
 grey degeneration of the columns is discernible by the 
 naked eye. Microscopically, the changes are the same 
 as are found in the brain, and are most marked in the 
 posterior columns, less in the lateral, and least in the 
 anterior. 
 
 13. INSANITY OF EPILEPSY. 
 
 Insanity is associated with epilepsy in many ways. 
 We have seen that idiocy is often associated with 
 epilepsy, and is often said to be due to it when the 
 epilepsy begins in very early life. But we have no 
 warrant for concluding that the idiocy is the result of 
 the epilepsy, which is itself but a symptom of some 
 grave irregularity in the mode of working of the nerve 
 elements. It is more likely that the same defect in 
 the constitution of the nervous system, which displays 
 itself in idiocy, has in epilepsy another of its mani- 
 festations. And similarly, when it is said that long- 
 continued epilepsy at length brings about insanity, we 
 are arguing post hoc, ergo propter hoc, without sufficient 
 warrant. Long-repeated epilepsy indicates a long-con- 
 tinued morbid condition of nerve tissue, and increasing 
 frequency of fits indicates increase of this morbid 
 condition, whatever it may be; and the insanity that 
 at length occurs may well be due to the same advance 
 of this morbid change that underlies the progress of 
 the epilepsy. So that, closely as epilepsy and insanity 
 are often associated, it is no more justifiable to regard 
 the epilepsy as the cause of the insanity, than to regard 
 the insanity as the cause of the epilepsy in those 
 numerous cases in which epileptic convulsions occur in 
 
188 TEXT-BOOK OF INSANITY. 
 
 the final stage of insanity. All that we are justified in 
 Diving is that insanity and epilepsy are very closely 
 associated. 
 
 Epileptics may be permanently insane, or their in- 
 sanity may occur only in connection with their fits. 
 The permanently insane epileptics are those whose 
 epilepsy has begun in early life, and who have never 
 been mentally sound, or those who, after life-long 
 epilepsy, have become demented. In the former, the 
 epileptic idiots and imbeciles, the depth or severity of 
 the imbecility or idiocy bears a general relation, not so 
 much to the severity of the fits, as to their frequency ; 
 and not so much to the frequency of the fits, as to 
 the earliness in life at which they began. The earlier 
 the epilepsy begins, and the more frequent the fits, 
 the deeper the idiocy. Epilepsy (by which we now 
 mean, not only the periodic convulsions, but the tissue 
 change which underlies it) which does not make its 
 appearance until puberty or later in life, does not, of 
 course, affect the mental development until it appears, 
 and the later it appears, the more complete the de- 
 velopment of brain and mind before they begin to be 
 interfered with. 
 
 The epileptic idiot is not different from other idiots 
 in any important respect except the fits, but the 
 epileptic imbecile differs much from other imbeciles. 
 He is usually more robust in body. He is taller, 
 bigger, more muscular, more energetic than other 
 imbeciles; he is often more intelligent, and he is 
 usually more industrious. Like most other imbeciles, 
 he is heavy, clumsy, slow, and awkward in his move- 
 ments; and withal he is irritable, passionate, and 
 quarrelsome. Epileptics are a turbulent, excitable 
 race, prone to quarrelling and violence. 
 
VARIETIES INSANITY OF EPILEPSY. 189 
 
 The epileptic dement is usually very demented. 
 His forehead and nose are often scarred from the 
 results of his falls, his aspect is heavy and dull, 
 his movements are slow, clumsy, and inffectual. Like 
 other epileptics, he is liable to outbreaks of impulsive 
 violence. 
 
 Other forms of chronic insanity fixed delusion, 
 persecutory delusion, mania, melancholia are not often 
 seen in epileptics as a permanent condition in the 
 intervals of the paroxysms. The form of the insanity 
 is simple defect or deprivation. 
 
 In connection with the fits, insanity may declare 
 itself before the paroxysm or after it pre-paroxysmal 
 or post-paroxysmal insanity. It has been described 
 also as replacing the fit, as an outbreak of rage or 
 acute mania taking place at the time the fit is due, 
 and unaccompanied by any fit. It is probable that 
 this outbreak is usually either pre-paroxysmal or post- 
 paroxysmal, the fit having been slight and unnoticed ; 
 but it seems as if a periodical outbreak does sometimes 
 occur, at a time and of a character that is regarded as 
 pre-paroxysmal, an outbreak which rises to a climax and 
 passes away without the actual occurrence of a fit. 
 
 Pre-paroxysmal Insanity. Epileptic fits often occur 
 with electric suddenness, and with no preceding or 
 premonitory symptoms to warn us of what is about 
 to happen ; but usually there is a warning, and the 
 warnings are of two kinds. The first kind of warning 
 is the aura, which is a part of the fit itself, and which 
 need not be described here, as it is fully dealt with 
 in works on general medicine. It lasts but a few 
 moments, and is soon superseded by, and lost in, th^ 
 other occurrences of the fit. The second kind of 
 warning is of much longer duration. It consists of 
 
190 TEXT-BOOK OF INSANITY. 
 
 a general alteration of disposition, always in the same 
 sense in the same case, which enables those who are 
 familiar with the patient to fortell the advent of a 
 fit for several hours, and often for several days, before 
 its onset. He becomes more and more irritable, 
 captious, ill-tempered, and apt to violence ; or he 
 becomes sullen, morose, silent, and very dangerous, 
 breaking out into frantic rage if interfered with ; or 
 he gets more and more stupid, heavy, dull, and 
 lethargic, until he may sit motionless for the greater 
 part of the. day, and be scarcely reusable to take his 
 meals ; or he is gay, excitable, talkative, and buoyant. 
 But whatever the condition, it is one foreign to his usual 
 and normal state, and it gradually becomes more and 
 more pronounced up to the time when the fit occurs. 
 Or, as has already been noted, it may culminate with- 
 out any observable fit, in some outbreak of violence 
 which is characterised by suddenness, and especially 
 by extreme, savage, reckless ferocity. Every few 
 months the country is startled by some crime of 
 horrible violence, in which the victim is not merely 
 killed, but the attack is pursued and continued after 
 life is extinct, until the body is mutilated almost out 
 of the semblance of humanity. The head is smashed 
 and battered into a pulp, or the body and limbs are 
 hacked and hewed with blind and revolting fury. 
 When the matter is investigated, it is found that 
 either there was no provocation at all, or that what 
 provocation was given was utterly and grotesquely out 
 of proportion to the terrible vengeance inflicted. Then, 
 upon still further investigation, it is found either that 
 the criminal is a confirmed epileptic, or more commonly 
 that he has " suffered with his head " ; that he has 
 been " very strange in his manner at times " ; that 
 
VARIETIES-INSANITY OF EPILEPSY. 191 
 
 other members of his family have been epileptic ; that 
 he has been subject to fainting fits ; that he has done 
 odd and unaccountable things; and, in short, that he 
 has given evidence by which we can conclude that he 
 has suffered from epilepsy, and that the crime that he 
 has committed was done towards the end of the pre- 
 paroxysmal stage of epilepsy. In such cases there is not 
 usually any actual fit. The maniacal violence seems 
 to take the place of the fit and to bring the occurrence 
 under the description of epilepsie larvee of French 
 writers. 
 
 Post-paroxysmal Insanity. When the alteration of 
 conduct and demeanour of the pre-paroxysmal stage is 
 prolonged and is well marked ; when there is a pro- 
 longed warning that a fit is coming on ; when the 
 modification of character gradually and continuously 
 increases up to the time of the fit; then, when the 
 fit does occur, it entirely clears all such symptoms 
 away, and the patient emerges from it in his normal 
 condition a condition which may not be one of wholly 
 sound mind, but which is normal to him. The time 
 immediately after the paroxysm is the time at which 
 he is at his best. His intellect is then clearest, his 
 temper least objectionable, his conduct most orderly. 
 Moreover, in the pre-paroxysmal state, in which he 
 is in some degree alienated, he is yet as fully conscious 
 as he is at other times. Post-paroxysmal insanity is 
 the reverse of all this. The patient as a rule preserves 
 his usual conduct and demeanour up to the very 
 moment of the fit. There is usually no warning at all 
 in the strict sense, though there may be an aura. The 
 fit is often very slight indeed, elaborate automatism 
 is not common after severe fits. After a fit, which 
 may be indicated merely by a momentary pallor, or 
 
192 TEXT-BOOK OF INSANITY. 
 
 aa instant of deviation of the eyes and head, or a 
 slight sinking at the knees, or some similarly trivial 
 manifestation, the patient enters upon a period of 
 action, which is distinguished by certain striking 
 peculiarities. In the first place, of whatever acts he 
 then does, he retains not the slightest trace of recollec- 
 tion afterwards ; and hence it is assumed that when 
 he does them he is wholly unconscious, an hypothesis 
 which gains corroboration from the nature of the act. 
 This is usually an habitual act. It is something 
 which the patient is in the habit of doing, and which 
 he can do with a minimum of deliberation and 
 attention ; or, rather, it is the caricature of some 
 such habitual act a caricature which is often nullified 
 or vitiated by want of appreciation of the circumstances 
 under which it is done. For instance, one of the most 
 frequent of these automatic acts is that of undressing; 
 and the patient will start to undress himself wherever 
 he may happen to be in the street, in a railway train, 
 at a dinner-party, anywhere. Or he will make water, 
 but instead of proceeding to a urinal, he will micturate 
 in a corner of the room or out of the window, or he 
 will use his hat or his beer-jug for a chamber-pot. 
 Or he will wind up his watch, but will stick the key in 
 anywhere it will go, or will use for a key any small object 
 that comes to his hand, or he will go on winding until he 
 breaks the works. Usually, whatever act a patient does 
 after one fit, that same act he will repeat after every 
 fit, but this is subject to a very important modifi- 
 cation viz., that if he find any implement in his hand 
 or handy, he will be very apt to put that implement 
 to its common use, or to some caricature of its common 
 use. If he happen to be holding a pen, he will make 
 marks on the surface before him. If he happen to 
 
VARIETIES INSANITY OF EP1LKPSY. 193 
 
 be holding a gun or pistol, he may load and fire it. 
 If he happen to be holding a knife, he may cut some- 
 thing with it. Thus it happened that a woman was 
 cutting bread and butter for her children's tea when 
 she had a fit, and in the subsequent automatism she 
 cut the arm of one of her children, so that it died ; 
 and in a similar way other quasi-crimes have been 
 committed. Usually the period of automatism after 
 the fit lasts for a few minutes only, but in instances 
 not very rare it is prolonged for hours ; and there are 
 cases in which, after a fit, the patient lives, as it were, 
 a new life, lasting for days, weeks, and even months. 
 It is quite a usual occurrence for a patient in post- 
 epileptic automatism to show some appreciation of 
 surrounding circumstances. I have seen one in this 
 condition walk for several hundred yards, getting 
 over a stile and a gate, and deviating from his 
 course when shouted at. But there are cases, re- 
 corded upon unimpeachable authority, in which the 
 patient has taken a ticket, has travelled a long 
 distance, put up at hotels, bought, sold, and trans- 
 acted other business ; and at length, after days or 
 weeks, has woke up to a recollection of all his former 
 life up to the moment of the fit, after which his mind 
 was an utter blank as to every experience that he 
 had undergone. The case then merges into one of 
 double or alternate consciousness. 
 
 In treatment, epileptic insanity requires nothing in 
 addition to the treatment of epilepsy and of insanity. 
 For the first, the main reliance is upon diminution 
 or abolition of meat in the diet, and the prolonged 
 administration of as large doses of bromides as the 
 patient is able to endure. In the dangerous out- 
 breaks, the administration of hyoscin will be found 
 
 13 
 
194 TEXT-BOOK OF INSANITY. 
 
 very effectual, and the status epileptieus demands 
 treatment secundem arteni by rectal injection of chloral 
 hydrate. 
 
 14. INSANITY OF BODILY DISEASE. 
 
 There are several bodily diseases which are connected 
 with insanity in the sense that those who sutler from 
 them are liable to insanity, which usually exhibits 
 much the same form in different cases of the same 
 bodily disease. There are other bodily diseases which 
 are connected with insanity in the sense that the 
 insane are peculiarly liable to them. 
 
 All exhausting diseases of whatever kind imply 
 some degree of dementia, to the extent that the patient 
 becomes incapable of strenuous intellectual labour; 
 frequently becomes irritable and fractious ; frequently 
 becomes weak of will, unable to stand out against 
 persuasion, and " facile," as the Scotch law calls it. 
 Cardiac disease, bronchitis, and other affections in 
 which the blood supplying the brain is imperfectly 
 aerated, are often attended with delirium. Heart 
 disease is often attended by feelings of dread and 
 anxiety, not necessarily referring to the bodily health ; 
 and gastro-intestinal torpor is usually accompanied by 
 gloom, depression, and irritability of temper. 
 
 The association of insanity with specific fevers has 
 already been referred to. In all specific fevers delirium 
 is common, and delirium is, of course, a form of 
 insanity. When delirium occurs after the fever has 
 declared itself and been recognised, it is easily 
 estimated at its proper value ; but when it occurs, as 
 it sometimes does, in typhoid, typhus, smallpox, and 
 other specific fevers, at the very outset of the malady 
 
VARIETIES INSANITY OF BODILY DISEASE. 195 
 
 and before the rash or other distinguishing character 
 of the disease has appeared, it is often regarded as 
 simple acute insanity, and the patient is sent to an 
 asylum, where the delirium subsides upon the appear- 
 ance of the rash. The thermometer is the safeguard 
 against such a mistake. 
 
 Phthisis is common among the insane, but apart 
 from this, there is a variety of insanity often asso- 
 ciated with phthisis and assuming much the same 
 form in all the phthisical patients who become insane. 
 The insanity often precedes the physical signs of 
 phthisis, and it is quite possible to predict the onset 
 of phthisis from the form that the insanity assumes, 
 together with the general bodily condition. The 
 form of the insanity is always that of sub-acute insanity 
 with depression, and delusions of suspicion. The 
 common form that the suspicion takes is that of being 
 poisoned. The patient refuses food, and when the 
 case is investigated, it is found that the refusal is 
 based upon suspicion that the food is poisoned. The 
 patient is feeble, languid, idle, and in addition is 
 irritable, morose, and suspicious to an insane degree. 
 All that is done for her (it is, I think, more frequent- 
 in the female) is misinterpreted and attributed to 
 evil motives and machinations. The physical signs 
 of phthisis are often not present in the lungs at first, 
 but there are loss of weight, feeble circulation, coldness 
 of the extremities, chilblains, deficiency of sleep, from 
 the beginning ; and when the physical signs do appear, 
 they usually progress rapidly. In many cases, however, 
 the course of the disease is protracted. The prognosis 
 is bad, but patients occasionally recover from the 
 insanity. 
 
 Gout is another disease which is occasionally, though 
 
196 TEXT-BOOK OF INSANITY. 
 
 rarely, associated with a fairly distinct variety of 
 insanity. The irritability and irascibility of gouty 
 people, when their attacks of gout are impending, are 
 proverbial, but when they become insane, the insanity 
 no more partakes of the nature of the mental tone 
 usually associated with the disease, than the insanity 
 of phthisis reproduces the spes phthisica, or the insanity 
 of pregnancy the longings and caprices of that 
 condition. In the rare cases in which insanity has 
 been definitely associated with gout, the form of the 
 insanity has been that of acute depression. 
 
 Insanity is sometimes associated with uterine and 
 ovarian trouble, and in insane women the menstrual 
 period is usually marked by an exacerbation of the 
 insanity, but no definite variety of insanity has been 
 identified as characteristic of disease of these organs. 
 
 In myxoedema occurs a very characteristic set of 
 mental symptoms, often amounting to insanity. The 
 patient subsides into a mild degree of dementia, 
 with great sluggishness both of mind and of conduct. 
 Thought is slow, memory is impaired, speech is slow, 
 and all movements are very deliberate. This placid 
 sluggish condition is sometimes varied by fretfulness 
 and irritability, and then outbreaks of actual mania 
 sometimes occur, and in these cases there may be 
 delusions, usually of suspicion, and hallucinations. 
 Myxoedema is greatly improved by thyroid feeding, so 
 long as the feeding is maintained, and the mental 
 symptoms usually improve and maintain their improve- 
 ment along with the bodily ; but the} 7 are very prone 
 to relapse if the thyroid is discontinued. 
 
PART III. 
 
 THE LEGAL RELATIONS OF 
 INSANITY. 
 
 197 
 
CHAPTER VIII. 
 
 THE LEGAL RELATIONS OF INSANITY. 
 
 THERE are four occasions on which a medical 
 practitioner may be brought into contact with the 
 law in dealing with insane persons : 
 
 1. In the placing of an insane person under control. 
 
 2. In the keeping of an insane person under control. 
 
 3. In connection with the validity of wills and 
 contracts. 
 
 4. In connection with responsibility for criminal 
 acts. 
 
 The legal formalities necessary for depriving an 
 insane person of the management of himself and his 
 affairs, and for detaining him under care and treat- 
 ment, differ much in different countries, and in 
 each country in different cases. The procedure is 
 different in England and Wales, in Scotland, and in 
 Ireland. 
 
 IN ENGLAND AND WALES 
 
 the procedure varies in the following circumstances : 
 
 I. According as the patient is an idiot or a lunatic. 
 
 A person, who has been from birth or from early age 
 
 idiot or imbecile, can be placed, under the provisions 
 
 of the Idiots Act, 1886, in an institution registered 
 
 under that Act, upon the certificate of one medical 
 
 199 
 
200 TEXT-BOOK OF INSANITY. 
 
 practitioner, accompanied by a statement made by the 
 parent or guardian of the patient. No order, judicial 
 or other, is necessary, and the medical certificate is a 
 simple statement in the following form : 
 
 I, the undersigned, A. B., a person registered under the 
 Medical Act, 1858, and in the actual practice of the 
 medical profession, certify that I have carefully examined 
 C. D., an infant [or of full age] now residing at , 
 
 and that I am of opinion that the said C. D. is an idiot 
 [or has been an imbecile from birth, or for years 
 
 past, or from an early age], and is capable of receiving 
 benefit from [the institution (describing it)] registered 
 under the Idiots Act, 1886. 
 
 Dated . (Signed) 
 
 II. When the patient does not come under the 
 description of an idiot or imbecile from birth or 
 from an early age, but has become insane in later 
 life, procedure varies according to the following 
 circumstances : 
 
 1. If the patient is wandering at large, he may be 
 arrested by the police and taken before a justice. 
 
 2. If the patient is not wandering at large, but 
 either is not under proper care and control, or is 
 cruelly treated or neglected by the relative or 
 other person having charge of him, then it is the 
 duty of the police and the parish authorities to give 
 information on oath to a justice, who will then take 
 the necessary legal proceedings. 
 
 3. In the ordinary case, in which the patient is 
 living at home with his friends, the procedure differs 
 according as he is or is not a pauper, by which is 
 meant according as his means allow of his being treated 
 as a " private " patient and of his support being paid 
 for, or as his malady must be treated at the public 
 
THE LEGAL RELATIONS OF INSANITY. 201 
 
 expense. It does not mean that he must be a pauper 
 at the time of his certification as a lunatic, but that he 
 becomes one by being certified at the expense of his 
 parish. 
 
 If he is in this sense a pauper, the affair is managed 
 by the relieving officer, and the only duty of the 
 medical practitioner is to make a certificate, which 
 is in the same form whether the patient is a pauper 
 or a private patient. 
 
 If, however, the patient does not satisfy any of 
 the foregoing descriptions, but is a private patient, 
 not wandering at large and not cruelly treated or 
 neglected, then there are three ways of placing him 
 under control, viz. : 
 
 The Judicial Reception Order, 
 
 The Urgency Order, and 
 
 The Inquisition. 
 
 The first is the ordinary and normal procedure. In 
 order to procure a judicial reception order, a petition 
 must be presented by the nearest relative of the patient 
 to a magistrate specially appointed under the Lunacy 
 Act, 1890; and the petition must be accompanied by 
 a statement, also made by a relative, and by the certifi- 
 cates of two medical practitioners made independently 
 of each other that is to say, the certificates must 
 be on separate sheets of paper, and the examination 
 made for the purpose of certifying must be made 
 " separately from any other practitioner." 
 
 The requirements of the certificates are simple and 
 easily satisfied, but it is seldom that they do not con- 
 tain some gross defect that could have been avoided 
 by a little ordinary care. The majority of certifying 
 practitioners do not even trouble to refer to all the 
 marginal notes and to see that all are satisfied, nor 
 
202 TEXT-BOOK OF INSANITY. 
 
 do they read .through the certificate when made, to 
 delete redundant words, and see that it reads gram- 
 matically and logically from beginning to end. 
 
 In making a certificate, its purpose must be con- 
 stantly borne in mind. It is to satisfy the mind of 
 the magistrate, a third person, who has never seen 
 and knows nothing of the patient, that the patient 
 is insane and a proper person to be detained under 
 care and treatment as an insane person. Students 
 usually make a certificate as if it needed to contain 
 a diagnosis, or as if it were a clinical description 
 of the case, and accordingly they put among the 
 " facts indicating insanity " their observations on the 
 knee jerks and the pupillary reflexes, and the age and 
 complexion of the patient. If they would only pay 
 attention to the terms of the document, and remember 
 that what is required of them are " facts indicating 
 insanity observed by myself at the time of examina- 
 tion," they would be saved from many absurdities. A 
 medical certificate of lunacy has by statute the force of 
 a statement made upon oath, and therefore should be 
 drawn with the same punctilious care as an affidavit. 
 The essentials of a good certificate are three : 
 
 1. It should be sufficient that is to say, the facts 
 stated as indications of insanity should be such as to 
 carry to the mind of the magistrate, who has never seen 
 the patient and knows nothing of him, a conviction 
 that the patient is insane. It is not enough for the 
 certifying practitioner to satisfy himself on this point. 
 He must so state his facts as to satisfy the magistrate, 
 and he must remember that the magistrate has not the 
 knowledge of the patient that he himself has. To 
 the doctor, who knows well the circumstances of his 
 patient, it is a fact indicating insanity when the 
 
THE LEGAL RELATIONS OF INSANITY. 203 
 
 patient deplores his own poverty and ruin, or declares 
 that his wife has deserted him. But to the magistrate, 
 who knows nothing of the patient or his circumstances, 
 these statements do not carry insanity, for, for aught 
 he knows, they may be true. When the " fact 
 indicating insanity " does not carry insanity upon the 
 face of it, it should be supplemented by a statement 
 that it is incorrect, and, if need be, by a further 
 statement that the patient continues to hold it in spite 
 of plain evidence to the contrary. That " he thinks 
 his wife has deserted him " is of itself no evidence of 
 insanity ; but that " he thinks his wife has deserted 
 him, although she was in his room ten minutes ago, 
 and left it for the avowed purpose of posting a letter " 
 is evidence. 
 
 2. The certificate should be definite. It should 
 give " facts indicating insanity," not opinions which the 
 certifier mistakes for facts. To say that the patient 
 " feels miserable," that he " believes he has committed 
 the unpardonable sin," that " he thinks he is king cf 
 the world " are not observed facts, but inferences from 
 observed facts. What is actually observed is that the 
 patient SAYS this or the other. Whether his mind 
 is in accordance with his statement is a matter of 
 inference, not of observation, and hence the statements 
 in a certificate should be limited to what the patient says 
 and what he does, and should not ramble into what he 
 thinks and feels. Neither has the certifier any business 
 to aver that the patient " cannot remember" this or " will 
 not answer " that. All that he can observe is that the 
 patient DOES not do what is required of him. Whether 
 this defect is defect of ability or defect of will is beyond 
 his power to determine. When you are giving evidence 
 upon oath you must distinguish carefully between what 
 
204 TEXT-BOOK OF INSANITY. 
 
 you observe and what you infer, and the observation 
 alone can be legitimately stated as a fact. 
 
 3. Lastly, the certificate must be clearly expressed. 
 Unless you are a master of English composition, keep 
 your sentences short, and do without qualifying clauses. 
 Above all, avoid entanglements with the personal 
 pronouns. You are not bound to give any " facts com- 
 municated by others." If the facts that you yourself 
 observe are sufficient to prove your case, there is no 
 need of facts communicated by others. But if your 
 own facts are weak and need corroboration, then you 
 must reinforce them by communicated facts ; and never 
 forget, what is usually forgotten, to give the name, 
 Christian names, address, and description of your 
 informant. By the " description " is not meant, by the 
 way, the complexion, colour of eyes and hair, etc., of your 
 informant, but his rank in life, occupation or profession. 
 Having given these particulars with respect to your 
 informant, state the information that he gives you in 
 as unambiguous terms as possible, making it clear 
 to whom your pronouns refer. Here is a specimen of 
 the kind of statement that ought to be avoided : " The 
 patient states that he knew Mr. M. in Australia, and 
 that he has often visited him at his house there, and 
 that on one occasion he went into his house and ate 
 the dinner that had been prepared for him." Who was 
 the visitor, whose was the house, and whose the dinner 
 are here left in uncertainty; and it is obvious that, 
 on one reading of the statement, the fact that one man 
 went into his own house and ate his own dinner is 
 alleged as a reason why another man is to be considered 
 insane. 
 
 The second method by which a " private " patient 
 may be placed under control is by means of an urgency 
 
THE LEGAL RELATIONS OF INSANITY. 205 
 
 order, but this method is purely a temporary expedient 
 to obtain immediate control of a patient while the usual 
 order by judicial authority is being obtained. It takes 
 time to obtain a judicial reception order, and there are 
 cases in which it is expedient that a patient should be 
 placed under control at once. For these exceptional 
 cases the urgency order is provided. By its means a 
 patient can be placed under control within an hour 
 or two, and the urgency order will remain in force for 
 seven days, or if within seven days a petition for a 
 judicial reception order is presented, then until that 
 petition is disposed of. 
 
 The urgency order must, like the petition, be signed 
 if possible by a near relative of the patient, and in any 
 case the person who signs it must be of full age, and 
 must within two days have seen the patient. It must 
 be accompanied by one medical certificate, and by a 
 statement of particulars similar to that which accom- 
 panies a petition. In addition to the medical certificate, 
 which is in precisely the same form as those which 
 accompany the petition, a further certificate must 
 be given by the medical practitioner in the following 
 form : 
 
 I certify that it is expedient for the welfare of the said 
 A. B. [or for the public safety, as the case may be~] that 
 the said A. B. should be forthwith placed under care and 
 treatment. My reasons for this conclusion are as follows : 
 [state them]. 
 
 By this means a case of acute mania can be got 
 under control at once ; a patient who is taken ill in an 
 hotel or a lodging-house, or who arrives insane on board 
 ship, can be immediately taken to a place of safety. 
 
 The inquisition is a purely legal procedure, and the 
 only function of the medical practitioner in connection 
 
206 TEXT-BOOK OF INSANITY. 
 
 with it is to make an affidavit and to give evidence 
 whm called upon. It results in the appointment of a 
 committee of the estate to admininster the financial 
 affairs of the patient, and of a committee of the person 
 to direct how the patient shall be cared for, and to be 
 responsible for his personal welfare. 
 
 IN SCOTLAND. 
 
 Idiots and imbeciles under eighteen years of age 
 may be received into training schools in Scotland 
 without even the small formalities which are needed in 
 England and Wales ; but in practice all such cases are 
 sent to such institutions as lunatics, with the usual 
 formalities required for lunatics, in order that thereby 
 the Government grant may be obtained. When above 
 the age of eighteen arid when sent to institutions other 
 than training schools, idiots and imbeciles are classed 
 as lunatics, and are subject to the same formalities 
 
 Insane persons ivhose malady is not confirmed may 
 be placed in private care for a period not exceeding six 
 months, under the certificate to that effect of one 
 medical practitioner. 
 
 Insane persons, whether pauper or non-pauper, can 
 be placed in institutions upon an order of the sheriff, 
 which is obtained by petition, accompanied by a 
 statement of particulars and the certificates of two 
 medical practitioners. In the case of a pauper, the 
 petitioner is the inspector of poor. 
 
 The English urgency order is paralleled by a certificate 
 of emergency given by a single medical practitioner, 
 and accompanied by a request from the person in the 
 position of petitioner, to the superintendent of the 
 institution, to receive the patient. 
 
THE LEGAL RELATIONS OF INSANITY. 207 
 
 By interdiction a person who is prodigal or facile 
 that is, too easily influenced by others can be restrained 
 from alienating his property without the consent of 
 guardians, called interdictors, who are appointed by the 
 court. This provision has no parallel in English law. 
 
 The English inquisition is paralleled in Scotch law 
 by the proceedings of cognition and curatory. The 
 curator appointed by the court administers the estate 
 of the lunatic, but there is no functionary corresponding 
 to the committee of the person. 
 
 IN IRELAND. 
 
 The formalities differ according as the patient is to 
 be taken to a district asylum or to a licensed or 
 unlicensed house. 
 
 Pauper patients who are not dangerous require 
 for their admission into a district asylum four docu- 
 ments : 
 
 1. Declaration before a magistrate stating that the 
 patient is insane and destitute, and giving the names, 
 addresses, and descriptions of two relatives of the 
 patient. 
 
 2. The certificate of a magistrate and of a clergy- 
 man or poor-law guardian that they have personally 
 inquired into the case. 
 
 3. One medical certificate. 
 
 4. An engagement by the applicant to remove the 
 patient when called upon to do so. 
 
 Paying patients who are not dangerous require for 
 admission into a district asylum even more documents 
 than the foregoing, viz. : 
 
 1. A declaration before a magistrate that the patient 
 has not sufficient means to pay for his support in a 
 
208 TEXT-BOOK OF INSANITY. 
 
 licensed house, and has no friend who can do so; 
 and stating how long the patient has been resident in 
 the country. 
 
 2. The certificate of a magistrate and a clergyman 
 that the case has been investigated. 
 
 3. One medical certificate signed by two medical 
 practitioners. 
 
 4. An engagement to remove the patient when 
 called upon to do so, and to pay a specified sum for 
 his support. 
 
 5. The sanction of an inspector of lunatics. 
 
 As might have been expected, proceedings so 
 cumbrous are in practice never employed, and practically 
 all the patients in the district or public asylums of 
 Ireland are admitted as dangerous lunatics, having 
 been apprehended " under circumstances denoting 
 derangement of mind, and an intention of committing 
 an indictable offence," and removed by warrant from 
 gaol to the asylum. 
 
 Into licensed houses, charitable institutions and 
 single care in Ireland patients are admitted upon the 
 following documents : 
 
 1. An order by a relative or connection of the 
 lunatic. 
 
 2. A medical certificate signed by two medical 
 practitioners. 
 
 In cases of urgency the signature of a single 
 practitioner is sufficient, provided that a second be 
 added within fourteen days of the first. 
 
 The proceedings, under inquisition are practically 
 the same as in English law. 
 
 In connection with the placing of an insane person 
 under control, and generally in connection with the 
 
THE LEGAL RELATIONS OF INSANITY. 209 
 
 examination and investigation of cases of insanity, a 
 warning must be given to the medical practitioner 
 never under any circumstances to lend himself to 
 deceit, or subterfuge, or cunning devices, in dealing with 
 his patients. There is a practice, unhappily still too 
 common, of regarding persons who are in any degree of 
 unsound mind as if all the ordinary canons of truth 
 and honesty were dissolved and obliterated in as far 
 as dealings with then are concerned. They are apt 
 to be looked upon as beings to whom everything may 
 be lightly promised, and with whom no promise 
 need be kept; who may be shamelessly deceived 
 without the natural consequences of deceit being 
 incurred. Such practices are utterly inexcusable, and 
 ought on no account whatever to be resorted to. When 
 a patient is to be examined with respect to his state of 
 mind, the only fair and proper course to pursue is to 
 explain to him, if he is sensible enough to understand 
 the explanation, what the object of his visitor is in 
 subjecting him to examination. And if it becomes 
 necessary to remove him to an institution, the necessity 
 should be pointed out to him, and he should be told 
 where he is going, and why. If he objects, he should be 
 reasoned with, and if reasoning and persuasion are of no 
 avail, he must be told that, if necessary, force will be 
 employed. Of course, if he is not sensible enough to 
 understand, this procedure need not be adopted, but even 
 then, no deceit should be employed to gain a temporary 
 advantage at the certain cost of much subsequent 
 trouble. 
 
 14 
 
CHAPTER IX. 
 
 KEEPING UNDER CONTROL. 
 
 THE law with regard to the custody of insane persons 
 is extremely stringent, and in these days, when every 
 medical practitioner, while waiting for his practice to 
 grow, seeks to eke out his income by taking a resident 
 patient, it is important that this should be known. 
 The terms of the Lunacy Act, 1890, are as follows : 
 
 "Subject to the exceptions in this Act mentioned, a 
 person. . . shall not be received or detained as a lunatic . . . 
 as a single patient, unless under a reception order made 
 by a judicial authority," etc. 
 
 " Every person who, except under the provisions of this 
 Act, receives or detains a lunatic or alleged lunatic in an 
 institution for lunatics, or for payment takes charge of, 
 receives to board or lodge, or detains a lunatic or alleged 
 lunatic in an unlicensed house, shall be guilty of a 
 misdemeanour, and in the latter case shall also be liable 
 to a penalty not exceeding fifty pounds." 
 
 " Except under the provisions of this Act, it shall not be 
 lawful for any person to receive or detain two or more 
 lunatics in any house unless the house is an institution 
 for lunatics or workhouse." 
 
 "Any person who receives or detains two or more 
 lunatics in any house except as aforesaid shall be guilty 
 of a misdemeanour." 
 
 It is unlawful, therefore, to receive into residence a 
 
 lunatic or alleged lunatic without a reception order, 
 
 210 
 
KEEPING UNDER CONTROL. 211 
 
 and only one such patient can be received into a private 
 house even with such an order. It matters not 
 whether a profit is made or no. Last year a medical 
 man was prosecuted for having, for payment, taken 
 charge of his brother, an "alleged lunatic," for having, 
 for payment, received him, and for having, for payment, 
 detained him in an unlicensed house. It was proved 
 that the Master in Lunacy was aware of and approved 
 the arrangement, and it was proved that the income 
 that the medical man received for his brother's keep did 
 not cover the charges for him, but nevertheless the 
 defendant was convicted of the technical offence. The 
 important question, upon which the whole of the section 
 practically hangs, is, What is an " alleged lunatic " ? 
 Without presuming to decide a legal point, it may be 
 stated that, as far as can be at present ascertained, 
 an " alleged lunatic " probably means a person who is 
 certifiably insane. 
 
 If, therefore, a medical practitioner or, indeed, any 
 one else desires to receive, for payment, a patient who 
 is certifiably insane, it is absolutely necessary that he 
 should refuse to receive the patient except upon a 
 judicial reception order, otherwise he may find him- 
 self liable to severe penalties. He must remember, 
 moreover, that when he does receive a patient under 
 a judicial reception order, he is at once responsible for 
 keeping statutory books and sending statutory notices 
 and reports, that he must submit to have his house 
 periodically visited and inspected, and his domestic 
 arj-angements criticised and reported upon, and generally 
 that he will be under supervision, and responsible, it 
 may be to more than one authority, for every detail in 
 the treatment of his patient. The numerous duties of 
 record and report cast upon the person who has charge 
 
212 TEXT-BOOK OF INSANITY. 
 
 of a patient in private care are far too lengthy to 
 set out here, and will be found in detail in " Lunacy 
 Law for Medical Men " (Churchill) by the present 
 writer. 
 
CHAPTER X. 
 
 TESTAMENTARY AND CONTRACTING CAPACITY. 
 
 IT may happen to any medical practitioner to be 
 called upon to give evidence as to the capacity of a 
 testator to make a valid will. It is not infrequent for 
 the family medical attendant to be called upon to 
 witness a will, and when he does so he should remember 
 that he does not do so as an ordinary witness, whose 
 attestation means merely that the signature of the 
 testator was attached to the will in the witness's 
 presence. When a medical practitioner attests a will, 
 his attestation means, not only that the testator 
 executed the will in his presence, but it means in 
 addition that the testator was at the time of sound and 
 disposing mind, and fit to make a will. The attestation 
 of the medical witness is a certificate of competency 
 given to the testator. 
 
 When there is any question of the capacity of a 
 testator, the following are the points to which the 
 examining practitioner should give his consideration : 
 
 1. Does the testator understand the nature of his 
 act ? that is to say, does he realise that he is making 
 a disposition of his property to take effect after his 
 death? Does he know whom he is benefiting and 
 whom he is excluding from benefit, and the extent to 
 which his legatees severally benefit under his will ? 
 
 213 
 
214 TEXT-BOOK OF INSANITY. 
 
 '2. Does he understand and appreciate the nature 
 and extent of his property ? It is not essential, of 
 course, that he should be acquainted with every detail if 
 he is a man of large property, but he should have a 
 general knowledge sufficient for the purpose. 
 
 3. Does he comprehend and appreciate the nature 
 of the claims to which he ought to give effect? that 
 is to say, has he a clear knowledge and recollection of 
 the existence of the persons that he excludes from his 
 will, and of the relation in which they stand to him ? 
 Has he sufficient intelligence to compare the claims of 
 different people upon his bounty ? And lastly has he 
 any such disorder of mind as shall " poison his affections, 
 pervert his sense of right, or prevent the exercise of his 
 natural faculties " ? Has he such insane delusion as may 
 " influence his will in disposing of his property, and 
 bring about a disposal of it which, if the mind had 
 been sound, would not have been made " ? To vitiate 
 the disposing power, it is not sufficient that the testator 
 should suffer from delusion. Many insane persons 
 suffering from delusions have made wills which have 
 been upheld by the court. To destroy the ''disposing 
 mind," the testator must not only suffer from delusion, 
 but the delusion must be of such a character as to 
 influence him in the disposal of his property. 
 
CHAPTER XI. 
 
 CRIMINAL RESPONSIBILITY. 
 
 THE third occasion upon which a medical practitioner 
 may be brought into contact with the law in dealing 
 with an insane person is in connection with criminal 
 responsibility. When the plea of insanity is raised in 
 a criminal case, the question left to the jury is, Did the 
 prisoner, at the time the crime was committed, know 
 the nature and quality of the act that he was com- 
 mitting and that it was wrong ? What amount of 
 light the medical witness will be allowed to throw upon 
 this question, supposing that he can throw any, will 
 depend upon the discretion of the judge who tries the 
 case, but the practice nowadays is for the judge to 
 allow a very wide latitude to the medical witness, and 
 for the latter to state his opinion very freely. In 
 doing so he should, however, not allow himself to be 
 influenced by any sentimentality or professional pre- 
 judice in favour of the plea of insanity, and there are 
 certain practical precautions which it is his duty to 
 take. In his interviews with the prisoner he should 
 furnish himself with writing materials and take down 
 the prisoners statements in the prisoner's own words 
 and in the prisoner's presence. He will then be entitled 
 to refer to his notes in the witness-box in order to 
 refresh his memory. He is, of course, entitled to 
 record anything that the prisoner may say about the 
 
 215 
 
216 TEXT-BOOK OF INSANITY. 
 
 crime and his share in it, and to ask him consequential 
 questions arising out of these statements, but he must 
 most carefully avoid asking the prisoner whether he 
 committed the crime, or putting to him leading questions 
 implying that the crime was committed by him. 
 
APPENDICES. 
 
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APPENDIX A. 
 
 219 
 
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 APPENDIX A. 
 
 
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APPENDIX B. 
 LETTERS OF INSANE PERSONS. 
 
 IN many forms and varieties of insanity letters are 
 never written. In other forms the writing of letters 
 forms one of the chief occupations of the patient, and 
 the letters are often very characteristic. 
 
 The two varieties in which the writing of letters is. 
 most characteristic are general paralysis and paranoia. 
 In sub-acute mania also, the letters written are often 
 very numerous. 
 
 In the early stage of general paralysis, the letters 
 are very numerous, and have the characteristics 
 already described. They very often contain orders 
 for the purchase of goods in great quantity. In 
 paranoia, the writing of letters is usually a very 
 prominent symptom, and the letters are often of an 
 extremely insane character when little or no indica- 
 tion of insanity can be obtained from the conversation 
 of the patient. The letters sometimes, but by no 
 means always, contain references to the persecution 
 from which the patient believes that he suffers. They 
 are sometimes neat and tidy, but more often are 
 written anyhow first a body of writing down the 
 middle of the page, then the margins are utilised, 
 then the writing is crossed, and perhaps recrossed 
 and interlineated. When all the paper has been 
 
 221 
 
222 APPENDIX B. 
 
 occupied in this way, ragged scraps are added, old 
 envelopes are utilised, margins of newspapers, pages 
 torn out of books, bits of paper bags, anything in the 
 shape of paper, and finally the letter is concluded on 
 the flap of the containing envelope, and often on the 
 outside of it also. The handwriting is usually very 
 bad, often illegible, and when deciphered, the con- 
 fusion of thought so characteristic of paranoia is very 
 conspicuous more so, usually, than it is in the con- 
 versation. Often there are long strings of words 
 from which no meaning whatever can be extracted. 
 Sometimes the manuscript is varied by sketches, or 
 by mysterious symbols and diagrams. The letters are 
 usually written to prominent people with whom the 
 patient has no acquaintance to the sovereign, to 
 the Secretaries of State, to foreign potentates, to 
 prominent politicians, philanthropists, actors, athletes, 
 to any one whose name is mentioned in a newspaper. 
 
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