/assh'e atrophy; the cells appear to be diminished only in size, the smaller nerve-cells are indistinct, and the nerve processes seem to be fewer. In extreme degrees of this change some of the cells scarcely take carmine staining at all, although side by side with them are found others showing the normal degree of imbibition of the staining fluid. It has even been claimed by Forster and others that calcification occurs under similar circumstances. All this suggests that a gradual deteriora- tion from the highh' protoplasmic character of the nerve- cells has taken place. This condition is found in that apathetic dementia which follows melancholia and stupor- ous insanity. The second series of changes is of more common occur- rence. It is an intensification of that normal involution of the nerve-cell which takes place with advancing years. While the pigmentation of the nerve-cells of the healthy cortex is in middle life limited to the larger pyramidal cells, it extends to the smaller ones in chronic insanity. While the pigment granules of the normal brain-cell are exceed- ingly fine, and do not appear to affect the fibrillar}^ struc- tures of the cell protoplasm ; in the diseased condition the pigment is in clumps, consisting of coarse granules, ob- jj^tUf scuring or crowding a mong the nucleus, and obliterating /r the fibrillary structure referred to. This change seems to produce different results when it affects the smaller nerve- cells. These are often converted into an apparently homo- geneous yellow substance, without any alteration in shape ; the nucleus shares in this change in a lesser degree, but does not lose its outline or distinctness. Inasmuch as with this class of changes it is common to find morbid states of the blood-vessels, it is reasonable to regard the recorded pig- mentary-granular change of the nerve-cells as the result of active nutritive disturbance. The final phase of this change. THE MORBID ANATOMY OF INSANITY. 105 a destruction of the nerve-cell,* is noted in the larger pyra- mids in extreme dementia, just as it is a regular occurrence in advanced senility. It manifests itself by the obscuration or disappearance of the nucleus, and the separation and disappearance of the cell processes. Finally, nothing but an irregular mass of granules and pigment serves to mark the former site of the ganglionic element. Observers have spoken of this process as a fatty degeneration or a fatty pigmentary change. But micro-chemistry, while it has not yet revealed the exact nature of these bodies, has demon- strated that they are not of a fatty nature. And it may be a proper place to insist here that the current statement, repeated in more than one text-book on physiology, and copied into several treatises on insanity, that the active ph)''siological ingredient in the brain is a " phosphorized oil or fat," is absolutely erroneous. The healthy brain con- tains no true fat, and the various reports of fatty degenera- tion of the diseased brain will have to be very carefully sifted in the light of modern chemistry before they can be accepted. The recorded proofs of fatty degeneration seem to rest on the reaction of the alleged fatty material to ether. But ether affects other substances than the fats in a similar way. Changes in the Neuroglia. — The so-called nuclei of the neuroglia, small round bodies which are derived from the formed elements of the blood, are frequently increased in number in insanity of long standing, particularly when it is accompanied by excitement. Unfortunately not enough is known of the true nature of the neuroglia to enable pathologists to explain a familiar change, common in ad- vanced deterioration. It is remarked that the longer a specimen of the brain cortex is hardened, especially if it be hardened in chromic acid or its salts, the more decided be- comes a certain fibrinous texture of the neuroglia. It is not determined thus far whether this network of fibrils is of a nervous or a connective-tissue character ; it certainly is the expression of a normal structure. The longer the harden- ing processes continue the more does this network con- tract, its meshes then widen, and numerous small roundish * It is customary to speak of nerve "cells," although it should be borne in mind that, in the strict histological sense, the ganglionic bodies of the cortex are not cells in the common acceptation of the term. I06 INSANITY. or oval cavities appear. Evidently the hardening process is accompanied by the solution and removal of some sub- stance and the condensation of the fibrillar network. Now what hardening does after a long period in a healthy brain that will it do in a much shorter time in the brains of some of the chronic insane, particularly in senile dementia. In- deed, a similar condition 'may be here determined in the fresh tissues, and is, therefore, undoubtedly pathological. Changes in the Blood-vessels. — The cerebral cortex is one of the most vascular tissues in the body. Among parenchymatous tissues it is exceeded in vascularit}'^ only by the blood glands. It is, consequently, but natural that some of the more important pathological changes of insanity should be found to commence in the intricate nutritive plexus of the cortical blood-vessels. The changes in blood- vessels may affect the structure of the blood-vessel itself, its contour, and its appendages. Structural Changes of the Vascular I Vail Proper. — Prolifera- tion of the nuclei in the vascular tissues and a fine granular or a colloid change of the muscular coat are common appear- ances. The term " colloid " here used has reference only to the optical appearance of the morbid deposit; it is not intimated that the latter has the composition of what is or- dinarily called colloid substance. It is also to be insisted on here, that the so-called colloid transformation of entire blood-vessels reported by some observers is due to the methods of hardening employed, and is therefore not a bo?ia- fide lesion. A general sclerosis of all the cortical vessels is a common condition in advanced insanity, and may be regarded as a sequel of the nuclear proliferation alluded to. In extreme cases this sclerosis reaches the degree of a fibrous transformation, the nuclei, previously abundant, now disappear as such, and the whole vessel may degene- rate into a fibrous filament, perhaps even devoid of a lumen. Changes in the Adventitia. — Much controversy has grown out of the claim that there are two lymph spaces around the cortical blood-vessels, one which is sub-adventitial and one which is extra-adventitial. There seems to be no doubt possible that while the space of His — that is, the perivascu- lar space — does not exist in health, it certainly exists in dis- ease, probably as a dilatation around the adventitia, compen- sating for the impeded lymph outflow through the natural sub-adventitial channel. This dilatation is accompanied by a dilatation of the peri-ganglionic spaces, and this latter THE MORBID ANATOMY OF INSANITY. lO/ reaches so extreme a degree, not only in paretic dementia (where it is most common), but also in advanced epileptic and periodical insanity, that the spaces resulting sometimes become visible to the naked eye. (See Fig. 2). This is the origin of the so-called e'tat crible of the cortex, which will be described in detail in the chapter on Paretic Dementia. The most constant morbid appearance in insanity is the deposit of granular and pigmentary material in the adven- titia. This is to be regarded as the result of repeated flux- ionary states, and is probably one of the earliest changes in progressive insanity, as indeed it is but an intensification of the same appearance, found on a greatly reduced scale, in every healthy adult. The granular pigment, usually of a yellowish, and rarely of a decidedly brownish tinge, is found accumulated in scattered foci or in larger patches along the course of the vessel, and particularly at the vas- cular bifurcations. While the arterioles which are visible to the naked eye show this change very markedly, the smaller vessels may be quite free from it. In advanced insanity, particularly of the epileptic and periodical types, and in clironic confusional insanity with excitement, profound changes in the direction and shape of the blood-vessels are frequent. The blood-vessels, which in a healthy state are straight or slightly undulating, in these conditions become tortuous, twisted, and redoubled on themselves, so that in exceptional instances, instead of a straight vascular tube, as in health, we have a pseudo-glo- merular coil. The calibre of the blood-vessel is also affect- ed; it is not equal, but irregularly dilated and constricted. Sometimes the dilatation resembles a minute fusiform aneu- rism, and an almost varicose condition is occasionally ob- served to accompany this. But in not a single autopsy has the writer observed that true miliar}' aneurismal condition which has been claimed to be so common in insanity. He questions whether, in view of the fact that miliary aneu- risms have been found by Virchow in healthy subjects, and unaccompanied l^y an)'' structural change, those found in the insane should be regarded as more than accidental or collateral conditions. It is a natural result of the weakening of the vascular walls, and the diminished resistance of the wasted sur- rounding tissues, as well as of the frequent fiuxionary epi- sodes of certain forms of insanity, that minute haemor- rhaofes and their traces are sometimes observed in the I08 INSANITY. cortex of the insane. It is also not difficult to bring the changes in the neuroglia and nerve-cells previously noted, into relation with the impeded transudation of nutritive material, through degenerated vascular tubes, and the re- tarded removal of effete products through the overstrained and blocked-up lymph passages of the degenerating brain. The observations made concerning anaemia and hyper- aemia of the brain after death, if we exclude paretic de- mentia and acute delirium, have very little value. The real condition as it was during life is generally obliterated by intercurrent disease, or by the mortuary changes. In a body which has been placed on the table with the face down, the frontal lobes may be found to be more injected than the occipital; if it is placed on its back, the reverse will generally be found to be the case. All these consider- ations show how uncertain the interpretation of so-called congestive or anaemic conditions must be, and how little value can be attached to the observation of a number of authors, who claim that in maniacal conditions the brain is found hypersemic, and in melancholiac ones anaemic, on the strength of the degree of injection found post-wortem. The condition of the brain as it was /////-a v/ta/// can be bet- ter determined by an examination, during life, of the vaso- motor system with our instruments of precision; and after death, by the morphological characters of the blood-vessels and the lymph spaces observed under the microscope. Di- lated lymph spaces signify obstruction to the lymphatic outflow; tortuous blood-vessels indicate a weakening of their coats through repeated overstrain. The former con- dition predominates with the atonic forms of insanity, the latter with those marked by excitement. Weight of the Brain. — It may be stated to be a gen- eral rule, that in chronic insanity generally the brain loses slightly in weight, and that the loss in weight increases with advancing deterioration, until in dementia it becomes considerable. In acute insanity and in early monomania there is often no perceptible difference from the healthy standard. Numerous brains may be found in the dead- house of an asylum exceeding in weight those found in the hospital dead-house, though the average is lower in the for- mer. In estimating the bearing of the loss in weight of the brain in insanity, the influence of intercurrent somatic af- fections must be also taken into account; for in ordinary chronic diseases without insanity a considerable loss in THE MORBID ANATOMY OF INSANITY. IO9 brain weight is often noted. Pfleger has found that the loss in weight in the sane dying of chronic diseases is about eight per cent, while in the insane the average weight is ten per cent below the normal average. The same observer, in his very careful measurements, found that the male brain suffers a greater loss in weight in insanity than the female brain, while Meynert arrived at the opposite conclusion. It seems to the writer that Pfieger's statement may have been made without reference to the original weight of the organ in the insane of the two sexes. In man)^ cases, particularly where there is a constitutional taint, there are evidences pointing to a primary deficiency in brain development. Inasmuch as the male brain is nor- mally larger than the female brain, both absolutely and rel- atively, and would presumably suffer more in congenital deficiency, it is apparent that a serious source of error has been overlooked by the Austrian pathologist. Neither the chemical anal3^sis nor the measurement of the specific gravity of the insane brain has led to results of sufficient importance to detain us here. Changes in the Brain Membranes. — In chronic insan- ity the membranes frequently show a morbid condition. It must be borne in mind, however, that many of the mem- branous changes found in insanity are also found in the or- dinary hospital population; while, on the other hand, brains may be found in persons who have been insane for a score of years, particularly among monomaniacs, whose mem- branes and tissues generally, may present a picture of ideal health ! Inflammation of the dura is rare in simple insanity, but is common in alcoholic, syphilitic, and paretic dementia. Its more characteristic features, as well as the morbid an- atomy of the meningeal blood cysts, which are by some considered to be the result of pachymeningitis, need not be detailed here, as they will come up for consideration in the analysis of the morbid anatomy of the disorders men- tioned. A very familiar appearance to the alienist pathologist is a milky-white opacity of the arachnoid which may affect the entire expanse of that structure. It is found in a large number of the chronic insane, and is usually asso- ciated with epithelial granulations of the pia, and increase in the size and number of the Pacchionian bodies. All these conditions indicate the existence of long-continued no INSANITY. vascular strain, with consequent exudation of formed ele- ments of the blood, causing cellular infiltration and thick- ening of the arachnoid lamellae on the one hand, and en- largement of the " safety diverticula" of the great cerebral veins, as which the Pacchionian bodies are to be regarded, on the other. All these conditions, however, occur in per- sons who never have been insane, and it cannot be main- tained that they in any way demonstrate the existence of insanity, though where found it is justifiable to bring these morbid appearances into relation with the mental disorder, inasmuch as far more numerous and intense examples of these changes are found in the insane than in the sane population. Even in the latter group, those showing any considerable degree of these changes are generally persons who have had syphilis, rheumatism, gout, been addicted to alcoholic excesses, or have suffered from exhausting chronic diseases. Although it is exceptional to find the pia adherent to the cortex of the insane, except in paretic dementia, in insanity with meningitis or syphilis, and in insanity following in- solation, this condition may be found in the terminal period of any psychosis, and has been discovered even in mono- mania, particularly when the course of this affection has been marked by a number of ^^/t^x/- maniacal exacerba- tions. There are sometimes observed in the insane, par- ticularly in those whose disorder has been of a chronic character, a peculiar series of meningeal changes, which seem to the writer to be interpretable as the evidences of a chronic and subdued inflammatory process which is not the cause of the insanity, but the result of prolonged insane excitement combined with the alcoholic excesses to which this sometimes leads. In a case of this kind — an imbecile with moral perversion and feeble ideas of aggrandizement, and who died with symptoms strongly suggesting the existence of an idiopathic organic brain trouble, — the fol- lowing conditions were found : On cutting into the dura of the right side a turbid fluid escaped. It was impossible to separate the dura from the other membranes over the frontal lobe, in an area corresponding to two thirds of its convexity. Here the leptomeninges and the dura were fused into a thick, dense common mass of membranous and pseudo-membranous layers, adherent to the cortex and inseparable from it. On vertical section, it was found that fibrino-purulent layers penetrated to the depth of the sulci THE MORBID ANATOMY OF INSANITY. Ill filled the meshes of the pia and arachnoid, and merged with the thickened and infiltrated dura into a combined thickness of more than half an inch at the focus of the dis- ease, which was over the posterior third of the middle and upper frontal gyri. The fibrino-purulent infiltration ex- tended further backward than the adhesion of the men- inges. The pia shows a distinct zone of a yellowish color, about half an inch in extent beyond the area of adhesion, and this zone detached peninsular processes along the chief vessels of the convexity. These, however, did not exhibit the creamy-yellow color of the chief disease area. On each side of the vessels a white or whitish-gray streak, varying from less than one to more than three millimetres in width, was noted. On cutting, this almost creaked under the knife; its consistency could be best compared to a well-sized parchment. In diminishing distinctness this peculiar con- dition could be traced as far back as the occipital lobe. It had every appearance in these districts of a lesion of ancient date, and the more active symptoms of focal cerebral dis- ease immediately preceding death were evidently due to an intensification of the lesion in the way of an acute and local exacerbation ; while the original mental deficiency was attributable to a congenital defect of the brain de- velopment, manifesting itself in gross asymmetry and atypy not only of the cerebral hemispheres but also of the peduncular tracts, and was altogether independent of the d-j progressive morbid process discovered after death. A number of morbid appearances are found in other parts of the body than the brain and its envelopes. But these are either concomitant lesions of other parts of the nervous system, such as the spinal cord, characterizing certain special forms of insanity, or trophic disturbances dependent on such lesions. In a comparatively small number of instances diseases of the viscera are found which have an intrinsic signification, and will hence be discussed with the forms of insanity dependent on such diseases. But it is to be insisted here that these cases are rather exceptional than the rule. The gross lesions fre- quently found in the chronic insane are usually the remote consequences of insanity or accidental accompaniments, and not its cause. For example, in hypochondriacal luna- tics and dements, whose psychosis began as a melancholia, it is not rare to find a dislocation of the transverse colon, whose loop may hang very low in the abdominal cavity. 112 INSANITY. This condition is undoubtedly due to the intestinal inertia, the resulting coprostasis, and consequent dilatation and loss of elasticity of the gut. Other of the lesions found in the insane are rather signs than causes of their disease; that is, they are either evidences of the obscure influence exerted by the mind upon the body, or of the trophic role played by the brain in the nutrition of distant organs, or, finally, local expressions of a deeper general somatic state, on which the insanity and the somatic signs in question rest in common. For instance, amenorrhoea in women, and torpor of the enteric tract in all sexes are concomitant to, and not causative of, melancholia. It is hardlj'^ neces- sary to refer here to the grave visceral lesions found with the paralytic insanities, which are results and not causes of the cerebral disorder, and whose analogues have been pro- duced through artificial cerebral lesions, in the lower ani- mals ; * nor to similar somatic changes, sometimes found in cases of advanced epileptic insanity.f Even palpable affections of the brain may be accidental accompaniments of a mental disorder, nay, even its indirect results! The cysticerci occasionally discovered in the brains of imbe- ciles, terminal dements, and paretics, developed from ova introduced with the materials devoured in obedience to the filthy propensities of such lunatics, are illustrations of the possibility of such a curious relation.]; From the statements just made it follows, that before a preternatural appearance, found in the brain of an indi- vidual dying insane, can be adduced to explain the nature of the mental sj'mptoms, or to illustrate the operation of * By Brown-Sequard, Leudet, Ollivier, Dupuy, Eulenburg, and others. JDufour, " Annates Medico-Psychologiques," 1880. Ullrich, " AUgemeine Zeitschrift fiir Psychiatrie," 1S72, xxix. Wendt, " Fall von Cysticercus im Gehirn, als Folge, nichtals Ursache der Geistes- storung." Ibidem, 1874. xxxi. Meschede, Ibidem, 1S73, xxv. The writer has frequently found cysticerci, single or in numbers not exceeding three, in monkeys of the genera macacus, cercopithecus, cynocephalus, and semnopithecus, occupying different gyri, including those most carefully studied by the localizationists. In none of these cases had any symptoms of cerebral disturbance been observed. It is, however, a beautiful illus- tration of the proposition that diffuse and multilocular lesions of the fore-brain always produce insanity, that in an earlier case of Wendt's ("AUgemeine Zeitschrift fiir Psychiatrie," xxv.), where beside numerous cysticerci found in the cereoellum and basilar parts, one hundred and thirty were found in the cerebral hemispheres, the insanity of the subject coincided with the probable period of their development, as it does in analogous cases found among domestic animals. THE CLASSIFICATION OF INSANITY. II3 an originally remote cause, it should be submitted to cer- tain tests. It must not only be shown to be independent of spontaneous changes occurring after death, and of arte- facta produced by the investigator, but it is also essential that the lesion be not one of the same kind, extent, and location as one found as frequently, or more frequently, in subjects dying sane. It is needless to remark that the same requirements are to be met, when it is attempted to establish a relation between diseased conditions found in other organs than the brain and a co-existing insanity. The connection between a given lesion and mental alien- ation having been rendered plausible after compliance with these preliminary demands, it remains to be ascer- tained whether the lesion as found is merely related to the particular phase of insanity as it existed before death, or whether it explains also the origin of the trouble. It is here to be insisted that, if the mental disorder is the terminal phase of a preceding series of mental symptoms, perhaps differing in character from their sequel, the dis- covered lesion can represent nothing more than the somatic basis of the terminal phase. It may enlighten us as to the basis of the preceding mental phases and the inception of the original evil in so far onh^as the principles of pathology permit us to infer from a post-mortem appearance what the initial steps of the morbid life-processes leading to it were. CHAPTER XI. The Classification of Insanity. While the proper classification of insanity which was initiated by the French and carried further by the German alienists may be said to be approaching a comparative state of perfection on the Continent generally, it is in America and England still in a very chaotic condition. Nearly every writer on insanity has offered a classification of his own. But while the student will find only slight differences between the classifications of a Marce, Dagouet, and Es- quirol, or a Krafft-Ebing, Schuele, and Meynert, and the gen- eral principle of their classifications is the same, he can only be confounded by a comparison of the systems of a Maudsley, 1 14 INSANITY. Hammond, Bucknill-Tuke, Skae, and Sankey. Suggestive hints and valuable demarkations may be found scattered here and there among the divisions of these authors; but, on the whole, the ambition to found new forms, often in- volving the doing away with the clinical principles which must underlie every practically available definition, and to establish formulae in place of following observations as a basis of classification, impair their usefulness. What could be more unfortunate than an attempt to classify insanity according to the faculties of the mind sup- posed to be affected in its various forms? Maudsley, one of the most progressive of English alienists, for example, divides insanity as follows: I. Affective or Pathetic In- ! II. Ideational insanity. SANITY. [ I. General. I. Maniacal perversion of the j a. Mania. j Acute and affective life. Mania sine deli- /i. Melancholia. \ chronic. no. 2. Melancholic depression with- out delusion. Simple melan- cholia. 3. Moral alienation proper. 2. Partial. a. Monomania, /i. Melancholia. 3. Dementia. \ Pr'^^ry •^ ( Secondary. 4. General paralysis. 5. Idiocy and Imbecility. Here we have mania and melancholia distributed under both heads; in one place as affective and in another as ideational insanity ! An attentive observer would often find that the same patient presents mania or melancholia without delusion at one period of his illness, and mania or melancholia with delusion at another. In fact there are few cases of insanity which would not be found to occasionally occupy a place in either of Maudsley's great groups. Such classifications are faulty, because the}' lack clinical unity and consistency. The same applies to several other systems of classification which are constructed on similar principles.* One of the most curious classifications is that which was recommended by a committee of the British Medico- Psychological Association in 1869, but not adopted by that body. The fundamental distinction is here made of "cur- * Maudsley has been selected as the most modern representative of the school which, with Griesinger and Prichard, made the mental com- plexion of the disorder the main guide in classification. He does not, therefore, stand alone, but his error has been a very general one; and there are those who have not yet emancipated themselves from it. THE CLASSIFICATION OF INSANITY. II5 able" and " incurable" forms. Let the reader imagine such a principle applied to any other class of diseases, say those of the intestinal tract ! The proponents of this classifica- tion seem also to have been aware of the existence of but one form of senile insanity, namely dementia. Morel was the first to admit the etiological principle into the classification of mental disorders. He divided insanity into — I. Hereditary Insanity ; 2. Toxic Insanity ; 3. Insan- ity due to the transformation of other neuroses, such as epilepsy and hysteria ; 4. Idiopathic Insanity; 5. Sympa- thetic Insanity; 6. Dementia. While this classification is defective on account of the insufficient stress laid on the clinical features of insanity, it must be regarded as the first step toward that more perfect classification which has been recently proposed and defended by Krafft-Ebing and other Germans. But a long period passed before this prin- ciple was properly asserted, for it was carried to an ex- treme, and rendered the vulnerable object of much ridicule by the English followers of Morel. Skae's twenty and more etiological forms, containing as they do much that is useful, include also a " post-connubial insanity," which may be anything from Mania and Melancholia to Paretic Demen- tia; a Mania of Oxaluria and Phosphaturia, which no in- vestigator has been so fortunate as to be able to confirm the existence of; and manias of "pregnancy" and "lacta- tion," which may be as often true melancholias as manias. Unable to make even his accommodating system fit all cases, Skae was compelled to erect an "Idiopathic" group, which, in truth, contains over one half of all the known and accepted forms of insanity. There is naturally no correct balancing of the main forms here! Dr. D. Hack Tuke improved greatly on the classifications of Skae and Morel, attempting to combine the metaphysical and etiological principles into one. But, by making the former the guiding and the latter the subsidiary element, he was led into such inconsistencies as the placing of Mania under " Intellectual Insanity," and Melancholia side by side with " Exaltation," and " Moral Insanity" under the " Emo- tional Insanity." There is also no placein his groups for paretic dementia. On the other hand, "Moral Insanity," placed by Dr. Tuke under the second order of the second class, that is, those occurring as an " invasion after devel- opment," maybe also a manifestation of imperfect develoD- ment, and therefore might fall under his first order as we'l Il6 INSANITY. The pathological principle has also been made the basis of classification. By none has it been carried further than by Voisin. He divides acquired insanity as follows:* I. Idiopathic insanity. a. Due to vascular spasm. II, Insanity dependent on appreciable brain lesions. a. Congestive insanity. b. Insanity from anaemia. c. Atheromatous insanity. d. Insanity consecutive to brain tumors. III. Insanity dependent on alterations of the blood. a. Diathetic insanities. b. Syphilitic insanities. This classification requires no extended discussion. Voisin's views as to congestion and anaemia in insanity are utterly fanciful, and it suffices to characterize the un- systematic application made by this author of his adopted principles, that general paralysis is widely separated from the other " idiopathic insanities" with " demonstrable brain lesions." Besides, Voisin claims to have determined a pathological basis for nearly every form and variety of in- sanity, and has in this respect either anticipated his age or has fallen into such multitudinous errors that it may be safe to pass by a project which may or may not be realized in the future, but which at present is decidedly unfeasible. One of the best classifications made within the last decade is that of KrafftEbing.f He divides insanity into two great * Le9ons Cliniques sur les Maladies Mentales, 1883. The classification offered by the same author in the edition of 1S76 is more elaborate. Unaccompanied by demonstrable lesions. Accompanied by demonstrable lesions. I. Active congestion. I. Acquired Insanity. J 2. Passive congestion. Idiopathic. ) 3. Simple anaemia. 4. Secondary anaemia. 5. Atheroma. 6. Tumors. b. Following the great neuroses. c. Sensorial insanity. d. Sympathetic insanity II. Congenital insanity, III. Toxic insanity. IV. Cretinism, idiocy, and imbecility. V. General paralysis. VI. Senile dementia. f " Lehrbuch der Psychiatric," II., 1879. THE CLASSIFICATION OF INSANITY. II 7 groups, according as the disorder is the result of a disturb- ance of the developed brain or of an arrest of brain develop- ment. Under the first head he places insanity ordinarily so called, and subdivides further as follows: A. Mental affections of the developed brain. I. Psychoneuroses. 1. Primary curable conditions. a. Melancholia. a. Melancholia passiva. ^. " attonita. b. Mania. a. Maniacal exaltation. /?. " frenzy. c. stupor. 2. Secondary incurable states. a. Secondary monomania (secundaere verrueck- theit). b. Terminal dementia. a. Dementia agitata. /?. Dementia apathetica. II. Psychical degenerative states. a. Constitutional affective insanity (folia rais- sonante). b. Moral insanity. c. Primary monomania (primasre Verruecktheit). a. With delusions. aoc. Of a persecutory tinge. y5/?. Of an ambitious tinge. /?. With imperative conceptions. d. Insanities transformed from the constitutional neuroses. a. Epileptic. /?. Hysterical. y. Hypochondriacal. e. Periodical insanity. III. Brain diseases with predominating mental symp- toms. a. Dementia paralytica. b. Lues cerebralis. c. Chronic alcoholism. d. Senile dementia. e. Acute delirium. B. Mental results of arrested brain development : idiocy and cretinism. Tl8 INSANITY. The criticism to be made of this classification is three- fold. In the first place, it does not accommodate itself to the fact that there is every connecting link between idiocy and imbecility on the one hand and monomania on the other. In the second place, the designation " Verrueck- theit" is too generally used, being made to apply to two very distinct forms of insanity. In the third place it is un- necessary, as it is inaccurate to add the adjectives "cura- ble" and "incurable" to the primary and secondary forms of the psychoneuroses, for in many cases the primary dis- orders are not cured by the very best treatment, and the stamp of incurability seems to be affixed to some cases from the start. It may be readily surmised that where the best thinkers have failed to produce an unexceptionable classification, the failure must be due to some inherent difficulty of the subject. Few cases of insanity are exactly alike in all re- spects. Here we have a patient whose insanity is charac- terized by a deep emotional tinge, there one with moral perversion, another with morbid propensities, and still an- other with fixed ideas. Here is an entire group of asylum inmates without hallucinations, illusions, or delusions; there another without dementia. Here is a ward filled with patients w^hose mental symptoms are accompanied by so- matic anomalies; there anothei-, in which no patient may be found whose somatic state differs appreciably from that of ordinary hospital patients. The course of this psychosis is chronic, of that one acute; while in some it is even, and in others progressive. In certain cases we find characteristic evidences of insanity in the dead bodies, in others not. Sometimes the psychosis is primary in origin, at others secondary to another psychosis. Often the insanity exists by itself, and often it accompanies and is determined in its existence by some other complaint. Several forms are hereditar}'^ or congenital, and others are independent of congenital and hereditary influences. More than one form of insanity is intimately associated with developmental periods, while the majority may appear at any time of life. In short, there is every possible association of factors seem- ing to distinguish various groups of the insane, and none of these can be altogether ignored in classification. For this reason all attempts to classify the form of insanity ac- cording to any one given invariable principle are predes- tined to failure. THE CLASSIFICATION OF INSANITY. II9 Let us walk through an asylum for the insane with an experienced alienist, and observe his method of diagnosti- cating and classifjnng the insane. He will not point out to the visitor any cases of " ideational," "atheromatous," or "post-connubial" insanity, but he will show him a mono- maniac, a melancholiac, a paretic dement, or a stuporous lunatic; and he will be able to pick out a large number of patients, place them together, and demonstrate the general sameness in the symptoms of all monomaniacs, or of all paretic dements, or of all patients belonging to any one of the other clinical groups. If he make any finer distinction, he may remark that in such and such a patient the disor- der is hereditary; that in this patient the delusions are de- pressive, in that one expansive, and occasionally he may allude to the fact that in certain patients the type of the disorder is determined by the etiology; that, for example, it may be alcoholic or epileptic in character. Let us now follow him to the "demented ward." Here he will exhibit a number of patients who seem to be all equally sunken into a condition of mental apathy and deterioration. But, on the alienist's directing attention to certain points in their past and present history, distinct types of "dementia" will become recognizable even to the novice. This patient who still exhibits a few faintly expressed delusions was originally a maniac, then his insanity became a chronic confusional delirium which has gradually passed into what is properly called a fermina/ dementia. A second patient has passed into a demented state by a gradual and progressive deterioration from a previous condition of mental health; his dementia is a. primary*' one, and not secondary to, nor the terminal epoch of some other form of insanity. A third has epileptic convulsions, and his dementia is the se- quel of epilepsy and consequently an epileptic dementia. A fourth has had a haemorrhage or other destructive lesion of the brain, and his feeble-mindedness is attributable to that; in other words, he suffers from donentia with coarse or- ganic disease of the brain. A fifth presents a peculiar and characteristic grouping of motor and sensory disturbances, and intellectual and moral perversion combined with men- tal failure, which in their union constitute paretic demen- tia. In still another patient the dementia is senile, because *This term has been used very confusedly; for explanation of the sense in which it is used here see " Primary Deterioration." 120 INSANITY. it is an expression of the involution of age. Finally, a pa- tient will be shown who is apparently in the lowest depths of mental annihilation; but the alienist assures the visitor that the disorder is not a progressive but a temporary one; that it is an overwhelming of the mind by some emotional shock, or the result of an episodial brain-exhaustion, and that in nine cases out of ten the patient will emerge from his present state clothed in his right mind. Such a case is one of so-C3.\\Q.d primary acute dementia, better known as stupor- ous insanity. As the novice is made better acquainted with the psychical features of these groups, he will find that the distinctions on which they are based do not exist alone in the antecedent history of the patients; but that as a gen- eral thing the character of the symptoms of each of them has something specific: that the senile dement is miserly and suspicious, the paretic dement boastful and extrava- gant, while tlie terminal dement is either apathetic or agi- tated according to the nature of his primary mental disorder, and that he often exhibits the residual delusions developed with the latter. If the origin and prospects of various cases of so appar- ently simple a disorder as dementia are so widely different as is here adverted to, it may be readily conceived that, with regard to the more positive manifestations of insanity, the distinctions must be still greater, and even more important as diagnostic and prognostic criteria. It would be mani- festly improper to place all patients manifesting maniacal excitement in one common group. Maniacal excitement may be an indication of a disorder consisting of this ex- citement as the sole prominent symptom, namely, of simple mania; it may occur as an episode oi paretic dementia and in epileptic insanity; finally, it may be the recurrent manifesta- tion of 3. periodical insanity, or characterize the explosion of a toxic affection. As insanity is after all but the sympto- matic manifestation of a brain disorder, and the pathological states underlying insanit)'^ are not well known, obviously the simplest and most profitable plan of classification will be the adoption of the clinical method as our main guide; then where etiology, pathology, and speculative psychology furnish valuable distinctions we may incorporate them as collateral aids in such classification. The first distinction to be made is between those cases in which the insanity is the directlv produced and most im- portant disorder manifested by tlie patient, and those in THE CLASSIFICATION OF INSANITY. 121 which the insanity is an accidental and inconstant accom- paniment of other diseases, and has its nature modified by these. The first group may be designated as that of the Pure Insanities, and the second as that of the Complicat- ing Insanities. Paretic dementia, simple mania, imbe- cility, monomania, and alcoholic insanity are the direct expression of d\sordQ.vs priinan'Iy attacking the brain; are fiot fiecessariiy dependent on any other disordered bodily condi- tion, and if attributable to such a condition are not thereby modified to any important extent. Rheumatic insanity, pellagrous insanity, and the post-febrile psychoses are essen- tially dependent on disorders which are not primarily cere- bral in their location, and their symptoms are specifically modified by an originally >ion-cerebral ca.usc. In the class of the " pure insanities" two great divisions must be made. There is one group comprising mental disorders which affect persons previously of sound mind, somewhat after the manner in which a fever or a diarrhoea attacks a person of previously sound bodily health. The insanity here is not the explosion of a continuous morbid condition, but stands by itself an isolated occurrence"^ in the midst of a relatively healthy career which it may check and end. The other group comprises disorders which are the explosions of a continuous neurotic condition, which may be inherited from a vitiated ancestry, acquired through intra- uterine or infantile brain disease, or developed under the influence of injuries to the skull and brain, or of excesses in the use of certain narcotics. In a rude way the first group corresponds to Krafft-Ebing's " Psychoneuroses" and " Brain Diseases with Predominating Mental Symp- toms" united into one class; the second group is nearly equivalent to the combined " Psychical Degenerative States" and " Mental Results of Arrested Brain Develop- ment" of the same author. Pure insanity not intrinsically dependSnt on a CONTINUOUS neurotic VICE is in turn divisible into sub- groups. The first is not associated with demonstrable active organic changes of the brain, while the second is so associated. Simple mania is a type of the first sub-group, paretic dementia of the second. Pure insanity not intrinsically dependent on a * Isolated in the sense in which the term may be applied to fevers or other affections of the kind. A recurrence is not excluded, but it is never typical. 122 INSANITY. CONTINUOUS NEUROTIC VICE, NOR ASSOCIATED WITH DEMON- STRABLE ACTIVE ORGANIC CHANGES OF THE BRAIN is again divisible into sub-groups. In a first subdivision we find in- sanities which attack individuals irrespective of the physi- ological periods of development and involution, while in a second subdivision they are intimately connected with such periods. Simple mania and melancholia are instances of the first kind, while insanity of pubescence is an instance of the second kind. Pure insanities not intrinsically dependent on a CONTINUOUS neurotic VICE, NOR ASSOCIATED WITH DEMON- STRABLE ACTIVE BRAIN CHANGES, NOR RELATED TO THE PERIODS OF DEVELOPMENT AND INVOLUTION include mOSt of the curable cases of mental disorder. They present themselves under two distinct forms, according as the dis- order is primary or secondary to one of the other forms of the same series. Simple melancholia and acute confusional insanity are representative of the Primary Forms, and ter- minal dementia and chronic confusional insanity are ex- amples of the Secondary Forms coming under this head. The PRIMARY INS.A.NITIES uot intrinsically dependent on a con- tinuous neurotic vice, nor associated with demonstrable active brain changes, nor related to the periods of development and involution^ consistently with the dichotomous division which happens to mark this branch of psyclnatrical classification, naturally fall into two categories. In one the insanity is always char- acterized by a fundamental emotional disturbance. To this category belong mania, marked by an exalted emotional state; melancholia, marked by a painful emotional state; katatonia, marked by a pathetic emotional state; and transi- tory frenzy. In the other category there is an absence of any profound emotional disturbance. To this category be- long primary dementia, stuporous, and acute confusional insanity. The SECONDARY INSANITIES belonging to the same sub-group include terminal detnentia and chronic confusional deterioration. Pure insanity not intrinsically dependent on a continuous neu- rotic vice, nor associated with demonstrable active organic changes of the brain, but related to the periods of development AND INVOLUTION, Comprises only two forms: insanity of pu- bescence (the hebephrenia of Hecker-Kahlbaum), and senile dementia. It is a matter of doubt whether a number of cases of insanity occurring at the time of the second climac- teric justify the erection of a special genus for their accom- modation under this head. THE CLASSIFICATION OF INSANITY. 1 23 The pure insanities which are not the outcome of a continu- ous neurotic vice, and are associated with active organic BRAIN changes, include paretic dementia, delirium grave (the manie grave of the Frencli), syphilitic dementia, and organic de- mentia. Under the latter term the mental defects accom- pan ving gross disease of the brain, such as cysticerci, tumors, h3'pertrophy, atrophy, sclerosis, and the ordinary cerebral vascular lesions are included.* The pure insanities which are the outcome of a con- tinuous NEUROTIC vice OR TAINT are those to whose patho- genesis the conclusions of the ninth chapter apply in great part. The neurotic vice may manifest itself in a gross and general defect in brain development as in idiocy; in lesser defects associated with anomalies in the cranial shape and peripheral growth and innervation, as in cretinism, imbecil- ity, and original monomania; in convulsions during child- hood; or in a generally neurotic constitution and mentally ab- normal character. The mental disorder may date from birth, from the period of puberty, or from the second climacteric, on the one hand, or it may be developed by exciting causes at any time of life, on the other. The neurotic vice is not necessarily transmitted; it may be acquired through trau- matism, and the formation of the alcoholic or other narcotic habit; and it may also gradually develop on the basis of any of the constitutional neuroses, such as epilepsy and hysteria. It is impracticable to separate the forms of these properly so-called constitutional insanities into subdivisions based on the intensity or character of the transmitted vice. Gross anatomical defects or lesser somatic indications of defective brain development are found indifferently in several of the forms of insanity belonging to this series; but they may be undemonstrable in the very same forms, and only the neu- rotic character may serve to characterize the predisposed person as a defectively organized individual. Attention has been already (Chapter IX.) directed to the fact that any form of insanity in this series may be transformed into an- other, and that the anatomical defects sometimes noted may be intensified in the course of hereditary transmission, or become potent in a descendant when they were absent in the ancestor. It was also observed at the same place that * This form will not be considered in this treatise, except in its dif- ferential diagnostic relations. 124 INSANITY. science was not yet able to determine what kind of anomaly determined the existence of a given form of hereditary or constitutional insanity. The same kind of asymmetry has been found in monomania and imbecility. A very natural distinction can be made between those forms in which the insanity is associated with the great neuroses, and those in which there is no such association, and if there be, that association is accidental. An idiot may have epileptic attacks, but his idiocy is not dependent on these, but on the brain-defect with which he was born. A monomaniac may have hysterical or epileptiform symptoms, though these are accidental to, and do not essentially mod- ify tlie monomania. But there are epileptic and hysterical patients who develop an insanity intimately dependent on the neurosis, and whose symptoms have a specifically epi- leptic or hysterical character. Similarly any lunatic be- longing to these groups may become an inebriate, but it is either a result or an accident in monomania, imbecility, and periodical insanity, while in the alcoholic maniac the insan- ity is the direct outgrowth of and modified in its symptoms by the acquired alcoholic neurosis. The pure insanities which are the expression of a continuous neurotic vice, but^ not dependent on the GREAT NEUROSES, Comprise idiocy, itnbedlity, creti/iic insanity, vwnoinania, and periodical insanity; those which are depen- dent ON THE GREAT NEUROSES Comprise epileptic, hysterical, and alcoJwlic insanity. The COMPLICATING FORMS are as numerous as the somatic causes which may determine the existence and modify the character of insanity. It is customary to designate that insanity following injuries to the skull and which has cer- tain specific clinical characters as traumatic insanity; that following rheumatism and gout as rhenmatic and gonty in- sanity; that accompanying chorea, as choreic insa?iity; that developing in the course of phthisis as phthisical insanity; and that due to powerful reflex influences as sympathetic in- sanity. Many of these forms are rare, others of only ex- ceptional occurrence, but they deserve a separate place be- cause their symptoms do not correspond exacth' to those of the " pure forms," and their treatment is directly to be based on the etiology. Indeed, they may be called the eti- ological forms. One form appertaining to this series, pellagrous insanity, will not be discussed in this volume, as it does not occur in America, and is limited to such countries THE CLASSIFICATION OF INSANITY. 12$ as Italy, where maize forms a staple article of diet, and where the disease known a.s pellagra, which is attributed to the living on spoiled maize, occurs in an endemic form.* A glance at the subjoined table will give a better idea of the proposed classification than any further description. It will be observed that on adding the designation character- izing the species to that of the genus and the class, a defi- nition of many of the enumerated forms can be compounded. Thus: Melancholia is a simple insanity, not essentially the manifestation of a continuous neurotic condition, not asso- ciated with demonstrable active organic changes of the brain, attacking the individual irrespective of the develop- mental and involutional periods, of primary origin and characterized by a fundamental emotional disturbance of a painful character. Insanity of pubescence is a simple in- sanity, not essentially the manifestation of a continuous neurotic condition, not associated with demonstrable active organic brain changes, attacking the individual in connec- tion with the period of puberty. Paretic dementia is a simple insanity, not essentiall}^ the manifestation of a con- tinuous neurotic condition, associated with demonstrable organic changes of the brain, which are diffuse in distribu- tion, primarily vaso-motor in origin, and destructive in their results. As a rule much briefer definitions will serve the purposes of the alienist, but the fact that the proposed classification carries with it the terms of these definitions will seem to many the strangest proof of its consistency. It is claimed in behalf of this classification, that while it is far from being above criticism in many particulars, it is calculated to meet the requirements of the practical alienist, in those respects in which the other classifications referred to fail. It may be objected to on the following grounds, and it is proper to take up those objections which can be antici- pated seriatim and at this point. It may be claimed that the maniacal symptom group being found in certain cases of periodical insanity as well as in simple mania, the two should not be widely separated. To this it may be answered that in simple mania, the emotional disturbance is the sole essential fea- ture, while periodical recurrence and a neurotic constitu- * The other complicating forms will be considered incidentally in the chapter on Etiology. 126 INSANITY. INSANITY. GROUP FIRST. PURE INSANITIES. SUB-GROUP A. Simple Insanity, not essentially the manifestation of a constitutional neurotic con- dition. FIRST CLASS. Not associated with demonstrable active organic changes of the brain. 1. Division. Attacking the individual irrespective of the physiological periods. Genus 5 : with simple impairment or abo- lition of mental energy. Stuporous Insanity Genus 6: with comusuniai adiiium. Primary Confusional Insanity Genus 7: wiih uncomplicated progres- sive mental impairment. Pi-inaary Deterioration P Order : Of secondary origin. Genus 8 : Secondary Confusional In- sanity Genus 9 : Terminal Dementia « Order : Of primary origin. Sub-order A. Characterized by a funda- mental emotional disturbance. Genus 1 : of a pleasurable and expansive character Simple Alania Genus 3 : of a painful characier. Simple Melancholia Genus 3: of a pathetic character. Katatonia Genus 4 : of an explosive transitory kind. Transitory Frenzy Sub-order B. Not characterized by a lun- damental emotional disturbance. II. Division. Attacking the individual in essential connection with the developmental or involutional periods. (A single order.) Genus 10: with senile involution Senile Dementia Genus 11: with the period of puberty Insanity of Pubescence (Hebephrenia) SECOND CLASS. Associated with demonstrable active organic changes of the brain. (Orders coincide with genera.) Genus 13 : which are diffuse in distribution, primarily vaso-motor in origin, chronic in course, and destructive in their results I'aretic Dementia Genus 13 : having the specific luetic character Syphilitic Dementia Genus 14 : of the kind ordinarily encountered by the neurologist, such as encephalo- malacia, haemorrhage, neoplasms, meningitis, parasites, etc. Dementia from Coarse Brain Disease Genus 15 : which are primarily congestive in character and furibund in development. Delirium Grave (Acute Delirium, Manie grave) SUB-GROUP B. Constitutional Insanity, essentially the expression of a continuous neurotic condition. THIRD CLASS. Dependent on the great neuroses (orders and genera coincide). I. Division. The to.xic neuroses. Genus 16 : due to alcoholic abuse Alcoholic Insanity (Analogous forms, such as those due to abuse of opium, the bromides, and chloral, need not be enumerated here, owing to their rarity.) II. Division. The natural neuroses. Genus 17: the hysterical neurosis Hysterical Insanity Genus 18: the epileptic neurosis Epileptic Insanity FOURTH CLASS. Independent of the great neuroses (representing a single order). Genus 19: In periodical exacerbations Periodical Insanity /-,..„ „„.„j j„„„i „„. t Genus 30 : Idiocy and Imbecility Order : arrested development ■, gg^,,^ 3, . cretinism Genus 22: manifesting itself in primary dissociation of the mental elements, or in a failure of the logical inhibitory power, or of both Monomania GROUP SECOND. COMPLICATING INSANITIES. These may be divided into the following main orders, which, as a general thing, are at the same time genera: Traumatic, Choreic, Post-febrile, Rheumatic, Gouty, Phthisical, Sympathetic, Pellagrous. THE CLASSIFICATION OF INSANITY. 12/ tion are necessary additional elements in periodical insanity. Inasmuch as these latter features determine the grave prognosis of periodical insanity, they are of greater prac- tical import, as they are certainly of higher significance, from an abstract pathological point of view, than the symptomatic direction in which the disorder manifests itself. Consequently the neurotic predisposition and peri- odical recurrence of the malady must as criteria determin- ing classification rank higher than the symptoms/^/- se. It may also be urged that heredity and the neurotic constitution, while they do not play as important a part in the simple as in the constitutional forms of insanity, yet they occasionally and in some forms, as in melancholia, quite frequently accompany the simple forms. But it is exceedingly rare for the patients suffering from a simple insanity to Q.xh\b\\. s. continuous neurotic condition, and where they do manifest it, then " simple" insanity attacks them, as an acute disease may attack a previously healthy individ- ual and evenly with one suffering from chronic disease or a constitutional vice but without any tangible connection with such chronic disorder or constitutional vice. An individual may inherit syphilis and become attacked by an acute pneumonia, but we do not speak of such a pneumonia as a syphilitic pneumonia; or another may have the tuberculous predisposition and die with a surgical affection, and while — this is said merely for the sake of offering an analogy — the statistics might show that more tuberculous subjects die of surgical affections of a given kind than non-tuber- culous subjects, yet until a more intimate relation could be shown between the vitiated constitution and the local disease, we would hesitate to speak of surgical affections in these cases as of the " tuberculous" variety. It is the same with insanity: certain varieties like monomania and imbecility are almost invariably associated with an ac- quired or transmitted neurotic vice, and on comparing a large number of cases exhibiting these forms of derange- ment it is found that there is on the whole a sameness in the origin and nature of the symptoms. On the other hand, simple mania, stuporous insanity, and other of the simple forms are not as a rule associated with such taint, may attack persons previously healthy and free from hereditary taint, and are noted for an absence of those characters found with the constitutional forms. Syphilis and the tuberculous diathesis are undoubtedly transmitted, 128 INSANITY. and the clinician is justified in characterizing- certain medi- cal and surgical affections from which subjects of such transmission suffer as the outcome of an hereditary or con- stitutional vice. But he will not place incidental affections of exactly the same character as those affecting the sane population — for example, ordinary catarrhs, attacks of in- digestion, of diarrhoea, or the exanthemata — in the same category with the results of the constitutional affection. Just as a syphilitic subject may become affected with small- pox, so an imbecile may become a sufferer from acute melancholia ; and just as a child afflicted with any hered- itary cachexia may be carried off by a scarlatina or diphthe- ria, so a monomaniac may end his days as a paretic dement. It is needless to add that the occasional development of one form of insanity in a subject already suffering from some other form is no more a ground for considering the two affections to be inseparable, than it would be just to classify peritonitis and impaction of biliary calculi as vari- ties of one and the same disease because the former may complicate the latter. One of the strongest objections to be advanced against the proffered classification is that alcoholic insanity and senile dementia are placed remotely from the forms which like paretic dementia and acute delirium are associated with demonstrable active organic changes. It is true that considerable organic disease may be found in senile de- mentia and in alcoholic insanity. But in the former dis- order these changes are the passive ones of involution, and not fresh processes attacking the previously sound brain. As to insanity developing on an alcoholic basis, those cases of it in which gross changes are found — changes which in that group of cases seem to stand in a constant relation to the symptoms — do not belong to alcoholic insanity proper, but constitute a variety of paretic dementia or insanity from coarse organic disease. The symptoms are then of an entirely different character, the morbid changes are both demonstrable and of an active kind, and the consistency of the classification proposed is nowhere better shown than here, where insanity which has a similar etiology, but a different clinical, pathological, and prognostic character from the alcoholic forms properly so-called, is removed from them by the terms of the definition heading the group in question. A further objection may be based on the fact that de- THE CLASSIFICATION OF INSANITY. 129 mentia from organic disease and dementia from cerebral syphilis are not ranked with rheumatic, pellagrous, and post-febrile insanity. It may be alleged that they should be so ranked because they are all equally among the un- usual manifestations of other diseases than those which fall within the ordinary ken of the alienist, and are hence true coiiiplicatiug forms. To this weighty objection it can be replied, that insanity from the physiological psychologist's point of view is a manifestation of brain disorder ; that we are correct in assuming that the ordinary psychoses are true cerebral affections, primarily of cerebral origin, and that it would be unwise from a patho-anatomical point of view — little as we actualh^ know of mental morbid anatomy — to separate the organic affections of the brain producing insanity, even though they produce it but occasionally, from the known and hypothetical diseases of the same organ producing those symptoms more regularly. Besides, by retaining the distinction between those forms which never exist without an essential extra-cerebral disorder from those in which a cerebral disorder is the primary determining factor, attention is prominently directed to certain useful therapeutical purposes. About one fact there can be no dispute, that, excluding the "complicating forms," the majority of the distinctions made will be recognized as necessary by the practical alienist. In a properly drawn up table of any asylum of over five hundred beds the reader will find that mania, melancholia, stuporous insanity, primary, terminal (second- ary), senile, and paretic dementia, dementia from organic disease, acute delirium, alcoholic, hysterical, epileptic, and periodical insanity, states of arrested development, and monomania — possibly under the more popular though less exact title of " chronic delusional insanity" — all have a place. It may be assuredlj' claimed that these distinctions having stood the test of time must possess a practical value. The day is past when the asylum physician can content himself with such a classification as this one.* Mania: acute, sub-acute, chronic, recurrent. Melancholia: acute, chronic. Dementia: primary, secondary, senile. Amentia (!): idiocy, imbecility. General paresis. * Taken from the annual report of the New York City Asylum for the Insane, dated January ist, 1879. I30 INSANITY. The average asylum attendants — and, in more than one in- stance noted by the writer, the asylum inmates themselves — are capable of mastering and — as far as an application can be spoken of — of applying such a system. When every excited patient is considered maniacal, every depressed one melancholic, every apathetic one a dement, and every stam- merer a paretic, there is simpl)' an end of scientific psych- iatry, and if sight can be lost for a moment of the pathological and clinical aspects of the subject, the reflection remains that such a classification is equally unfortunate from a practical point of view. It leads to that dangerous routine which gives chloral and conium to the excited, opium to the depressed, and nothing to the apathetic patient, merely because they are excited, depressed, or apathetic. While the same strong grounds advanced for the con- sideration, as separate forms, of those varieties of insanity mentioned at the opening of the above paragraph do not hold good with the others; that is, while the latter are not universally recognized to be as distinct as the former by eminent authorities, it is believed by the writer that they merit such consideration. For whatever disposition the future wull make of them, it may be confidently predicted that the symptom groups of transitor)' frenz}', primary confusional insanity, katatonia, and the etiological forms will continue to be subjects for study, and present im- portant problems of differential diagnosis, prognosis, and therapeusis to those alienists who analyze the symptoms of their patients not according to preconceived schemata, but in the light of the bed-side revelations. The clinical label may be changed, the clinical classification shifted or re- placed by a patho-anatomical one; but the clinical picture will remain forever. PART II. THE SPECIAL FORMS OF INSANITY. Sub-order A. The Simple Forms not Essentially the ManifesJations of a Con- u / stitutional Neurotic Condition. I First Class: Those not Associated with Demonstrable Active Organic Brain Changes. /. Division. Attacking the Individual Irrespective of the Physiological Periods. Orders: Of Primary Origin ; Sub-order \>: Characterized by a fundamental Emotional Disturbance. Simple Mania. Simple Melancholia. Katatonia. Transitory Frenzy. CHAPTER I. Mania. Mania is a form of insanity characterized by an exalted emo- tional state which is associated with a corresponding exaltation of other mental and tiervous functions. The typical condition of the maniac * may be summar- ized in one phrase: loosening of the inhibitions, or checks, both those of organic and those of mental life. The per- ceptions appear more acute, the associations are quick, so rapid indeed that the ease with which the patient forms new and extravagant mental combinations, and the readi- * It is not necessary to refer here to the fact that this word has been used in every possible sense, even in one equivalent to insanity as a whole. In these pages it is used in the limited sense: that is, " mania" without any qualifying clause refers to the condition treated of in this chapter alone. 132 INSANITY. ness with which novel suggestions present themselves, im- press the novice as manifestations of a naturally quick wit, or of a talented and original mind. It is particularly that faculty termed the fancy which is extraordinarily active, and the images crowd each other in such profusion that the patient in endeavoring to announce them later becomes unable to keep step with his words, and although his speech is much more rapid than in health he is compelled to break off in the middle of a sentence to begin the next, and thus gives the superficial impression that his ideas are confused, when in reality they are not, at least in the earlier periods. There is a discrepancy merely between the rapidity of the conceptional and associating transits and those of which the speech tracts are capable. Corresponding to the activity of the patient's thoughts he becomes declamatory in style, and his exaggerated manual gestures and the rapid play of his facial muscles indicate the nature of his disorder as well as his spoken words. He is not able to remain long in one placej'as it is impossible for him to remain long silent. The appetite and digestion are excellent, the sexual de- sires increased, the patient generally feels in high spirits; everj'thing presented to his mind is couleur de rose; in short his whole condition resembles an intensified sanguine tem- perament. He forgets the cares and vexations which may have led to his illness; happy and contented, it is his desire to make others so. He scatters his worldly possessions among his friends and even among strangers; invites them to festivals or to banquets; and indulgences in drink so frequently resorted to in this condition, like the venereal excesses which are often its earlier manifestations, sometimes intensify the worst developments of the disorder. If the maniac forgets the cares and troubles of this world, he becomes equally oblivious of the restrictions of its con- ventional and civil laws. All clogs and impediments are swept away by the rapid torrent of ideas and impulses overcrowding and jostling each other. Reflection has no time to exert its checking influence, and the beast in man comes to the surface. Men ordinarily reserved and women previously chaste display an animation in their looks, an obscenity in language, a lasciviousness in gestures and acts, and an obliviousness of propriety, shown in the publicity of the latter, which are among the most striking features of mania. MANIA. 133 With all this the patient is quick at repartee, defends his acts with sarcastic retorts, or explains them in a ^«<^-7^/^ >t^t^*^<-^ PRIMARY MENTAL DETERIORATION. 163 existence they previously admitted, and at most they speak of their former selves in the third pers on, o r manifest a confused variety of double consciousness.! vvnen the hal- lucinations, as is frequently the case, preponderate from the beginning, the disorder w^e have here considered is termed by some acute hallucinatory confusion. From the superficial resemblance of the verbigeration of patients exhibiting this form of insanity to monomaniacs with episodial delirium, Westphal was induced to classify it among the monomanias (Primare Verriicktheit) a most improper arrangement. It 'would be" as just to comprise almost every other form of insanity under monomania on the same basis. I In confu- sional insanit}^ there is no method as in monomania, no productiveness as in mania, no origin of the delusions from a process of reasoning and reflection as in the former, nor a flight of ideas as in the latter. Recovery is gradual, the patient becoming progressively clearer; his somatic complaints, such as headache, then occupy his attention more than his incoherently recounted delusive troubles, and finally reason is entirely restored. In only a small proportion of cases does the insanity re- main and the patient become permanently deteriorated, his disorder then appearing as a form of Mr^;z/V confusional insanity. CHAPTER VII. Primary Mental Deterioration. Primary 7ne7ital deterioration is an uncomplicated enfeeblement of the mind occurring independently of the developmental and in- volutional periods. In most persons surviving the sixtieth year a pronounced and general failure of the mental powers occurs at or after that period. This is the ordinary senile change, and can- not be considered to be in all cases a pathological one. But where a similar deterioration anticipates the senile period it can only be accounted for on a pathological basis. Such a decay of the mind is observed in paretic, syphilitic, and organic dementia, and is also found to be a sequel of nu- merous other forms of insanity. In all these instances the mental failure is accompanied by active symptoms which in 164 INSANITY. their association with the dementia characterize the given variety of mental disorder. It is not so, however, with a cer- tain class of cases in which progressive deterioration, chiefly limited to the higher mental faculties, is the only notable indication of a cerebral disturbance. Crichton Browne described as " chronic brain-wasting" a disorder in which there is confusion and failure of the memory, lack of attention, and general inertia. With this the muscular power is enfeebled, the articulation is af- fected, the pupils are unequal, and the temperature is sub- normal, while the patient generally complains of a sensa- tion of pressure or fulness in the head. Convulsive attacks occurring on one or both sides heighten the re- semblance to paretic dementia, and the progress of the disease, with rare exceptions in which recovery occurs, is toward complete extinction of the mental faculties. The writer has observed a similar condition among busi- ness men, particularh' among those whose duties were of a varied, exciting, and exhausting character, who, with an expensive domestic establishment on the one hand and a tottering firm on the other, resorted to Wall Street to make good the difference. It is also not uncommon with mem- bers of the legal and other professions, to the practice of which excitement and strain are incidental. In short, the etiology of this affection is very similar to that of paretic dementia, and it may not be improper to consider it an, as it were, functional analogue of that organic malady. The paralytic and convulsive symptoms noted by Crichton Browne have not been observed in the writer's cases, and, judging by the serious prognosis given by that author, it is probable that he has considered genuine cases of paretic, syphilitic, and "organic" dementia in conjunction with those cases to which the writer would limit the designa- tion "primary mental deterioration." The first signs noticed are generall)^ recognized by the patient himself. He experiences a lack of energy both mental and physical. The warning being disregarded, and the strain kept up, the abused nervous system replies with insomnia. The patient finds it difficult to go to sleep, and when he finally drops off into a brief and fitful slum- ber it fails to refresh him, and the irritable condition of his brain manifests itself in dreams, whose subjects are gen- erally taken from his daily occupations and cares. The patient now becomes dyspeptic, and signs of functional or PRIMARY MENTAL DETERIORATION. 165 organic heart disorder, or of the prodromal period of Bright's disease may be noted by the examining physi- cian. Often tlie patient becomes prematurely gray. There can be little doubt that continuous mental worry and emotional strain are competent to provoke all these dis- orders, particularly in predisposed individuals. At this stage the warning may be heeded, and a comparatively healthful mental state resumed under treatment; but if the exciting causey §5^..^£Pl ^^ operatio n actual dementia may be the result/^ At nrsi l^e subject is noted to be absent- minded: thelaWyer finds that he is unable to fix his atten- tion on his opponent's argumentation; the physician dis- covers that he is at a sudden loss in writing prescriptions and forgets to add important directions, not in single in- stances, but repeatedly; the stenographer finds that his hand fails him; and the literary man omits words, or mis- spells where he was previously methodical and accurate. Important engagements are broken, articles of value mis- laid, addresses forgotten, expenditures unrecorded, and, with the mtensification of all these symptoms, complete fatuity may be developed. Yet it is noteworthy that, while the memory fails, attention becomes difficult, and the power of acquiring new impressions is impaired, the patient may in fits and starts show his old brilliancy in reasoning. Let him, however, attempt to keep up the ef- fort any considerable length of time and he will break down. ^ ^ C^- On the basis of the condition just described any of the \^ primary simple psychoses may develop, and it may prove to be the preliminary phase of a paretic dementia. But it may also continue to exist by itself, and terminate in a rel- ative recovery or in death v^^itho ut further complication. 'As a rule complete rest and proper tonic and moral treat- ment are capable of checking the disorder at any but its later periods, and while a complete restitutio ad integrum has never been observed by the writer, and even the most fa- vorable cases reveal some permanent damage, however slight and however unnoticeable, to those who have not known the individual before his illness, some of the pa- tients remain free from a renewed attack, and may even return to business of a less exciting character, and success- fully fill a responsible position in life. This disorder rarely comes under the notice of the asylum physician. The absence of delusions, of morbid propensities, 1 66 INSANITY. and of excitement account for this fact. Occasional!}- a suicidal tendency may render sequestration necessary, and the mistake is apt to be made of confounding such a case with paretic dementia of a melancholic or hypochondriacal invasion-type. Add to this the fact that a laxity of the facial and a weakness of other muscles, as well as forget- fulness of words and facts, are common accompaniments,, and the possibility and probability of this error being com- mitted will be understood. The future history of the case exposes its true nature, and a careful analysis will show that the suicidal attempt was not the outcome of emotional depression, delusion, or hallucination, but the result of a process of reasoning, often correctly based on correct prem- ises, by a patient fully appreciating his sad position. The misery of the sufferer is often aggravated by his recog- nition of the fact that his affection for his dearest friends and relatives, like his more strictly intellectual faculty, has become blunted, and that he is unable to recall these feel- ings in that intensity which characterized them in his healthy state. CHAPTER VIII. The Secondary and Terminal Deteriorations, In the foregoingchapters on mania, melancholia, stupor- ous and other primary forms of insanity, reference has been repeatedly made to the fact, that in a certain series of cases, while death does not ensue, recovery is not effected; and a secondary and chronic psychosis develops from the primary disorder. A thorough consideration of dementia is nearly tanta- mount to a study of all that which the older authorities designated as " secondary forms." As the term is generally used, however, it refers to te?fninal dementia, v^hich is the or- dinary conclusion of most chronic, and the uncured acute insanities. Inasmuch as terminal dementia develops from primary forms differing greatly among themselves, and the transition from the primary insanity to dementia is gradual and progressive, it will be perceived that numerous grades and varieties of this affection must exist. It is customary SECONDARY AND TERMINAL DETERIORATIONS. 1 6/ in order to fully characterize their varieties, to state what primary form preceded the dementia. Thus we say: de- mentia follows mania, melancholia, or stuporous insanity^ Sometimes we are enabled to determine from the demented patient's symptoms what the primary form of his insanity was; in one case we may find residua of the delusions of marital infidelity with physical symptoms indicating the previous existence of alcoholic mania, in another the delu- sions of persecution, and incoherent ideas growing out of such, which point to the previous existence of melancholia. Dementia must not be confounded with imbecility; while both dementia and imbecility imply a profound general de- fect in the mental sphere, the former term should be always limited to acquired enfeeblejnent, the latter to the original feeblemindedness due to foetal or infantile arrest of develop- ment. Much confusion has also arisen from the unfortunate use of the terms "acute" and "primary dementia." Acute dementia is applied to a primary insanity more properly designated as acute stupor, while " primary dementia" is in- differently applied to stupor, insanity of pubescence, and primary deterioration. The designation dementia should be limited to permanent mental deteriorations, and a dis- crimination should be made between the dementia from gross organic disease of the brain, the paretic dementia to be considered in a later chapter, and that senile dementia which is a natural manifestation of brain-involution on the one hand, and the trouble we are here considering, which implies the previous existence of some well-marked primary form or the other. The course of the development of this secondary insanity is twofold: either the primary disorder passes directly into dementia, or it does so indirectly, through an intermediate stage of chronic secondary mania, with confusion of ideas and mental enfeeblement as prominent features. When dementia follows the latter affection it is " tertiary." But, as it does not in this case materially differ from the demen- tia which is a more direct sequence of and secondary to the primary forms of mental disturbance, it is best to de- vise some common term for both. The framing of such a term may be based on the fact that, whether secondary or tertiary, these varieties of dementia, in contradistinction to the primary dementia from coarse brain disease and senes- cence, are the tertnifial epochs in the history of prior psycho- sis. They may hence be termed terminal dementias. 1 68 INSANITY. In its widest sense this designation might apply also to the dementia which closes the history of epilepsy, as well as of epileptic and alcoholic insanity. But, as the dementia in these cases is customarily designated as epileptic, alco- holic, etc., according to its etiology, and these adjectives in- dicate also the clinical characters of dementias which are different from those of the dementia following the ordinary forms of insanity, the group of terminal dementia may be advantageously limited to the latter. For stuporous insanity and melancholia attonita it re- quires nothing further than for the patient to remain in the atonic and stupid condition a longer period than in favor- able cases to constitute a terminal dementia. Occasionally the exhaustion following violent outbreaks of maniacal furor passes into dementia as directly. In all these cases the mental deterioration is of a passive variety, one whose characters are simply negative; the mental processes gen- erally are nullified, the countenance is devoid of expression, the extensors are not innervated, the flexors consequently predominate, and the patients in their inactivity resemble cowering statues or animals whose cerebral hemispheres have been partly removed. What was a merely functional and temporary clouding of the mental sphere in atonic melancholiacs and the stuporous insane now becomes an organic, progressive, and permanent condition, which finds an anatomical expression in the accompanying cerebral atrophy. These unhappy creatures constitute a considerable pro- portion of the pauper asylum * or poorhouse population, and they largely people the " unclean" w'ards of all asylums. Here they may be seen on the benches, mute, expression- less, devoid of any spontaneity, requiring to be fed, con- ducted to the water-closet, dressed and brought to bed like children. As deterioration proceeds even the few words re- tained in their limited vocabulary become lost, and complete mental annihilation precedes physical death, which occurs either through the extension of central paralysis to the centres of vegetative life, or by inter-current diarrhoeas and pulmonary affections. As a rule these patients do not live more than a few years. Other demented patients appear docile, willing to assist * Of the 2,297 pauper lunatics, referred to elsewhere as tabulated ac- cording to their form of insanity by the author, 334, or over fourteen per cent, were terminal dements. SECONDARY AND TERMINAL DETERIORATIONS. 169 the attendants in the performance of routine duties, are em- ployed in copying records, in nursing debilitated comrades, and attending to the cattle on the farm, while the great ma- jority are lounging listlessly around the corridor, or stand or sit in one place all day, indulging in some rythmical movements, or vociferating the same set phrases. Some dements pass their evacuations without any regard to time and place, and even delight in doing so in the most unusual localities, and in the most unseemly manner; others do so because they are simply oblivious to the calls of nature. Certain of these patients require to be fed by force, others will eat as soon as the automatic processes are started by seating them at table, and putting eating utensils in their hands, still others are ravenous eaters, and their ideations revolve within the limits of the daily bill of fare, whose items perhaps they will recite or chant all day. The funda- mental feature of terminal dementia is an acquired mental defect, and this may vary from a mere loss of memory, usually of recent events, or of the reasoning power, to the nearly complete extinction of mind. The loss of memory may be of every grade; in some it involves a special period of life; in others the period of the primary disease; in all more or less the memory of recent events. Old recollec- tions may exist with normal intensity, but there is a failure of the receptive sphere to register new impressions, or at least to register them perfectly; indeed it is to be presumed that it is the struggle between the old healthily-established mental combinations, and the imperfect and hampered products of the newer ones, which accounts for the phenom- enon of double consciousness, and other disturbances of the sense of personal identity sometimes found in the early phase of terminal, as in other varieties of dementia. There is another form of terminal dementia in which apathy is not so pronounced, and inactivity cannot be said to exist. On the contrary, the patients are restless, talkative, and even obtrusive or destructive. But their violence is with- out purpose, and even without that emotional basis which, the maniac's violence always has. Their speech is verbose but the sentences are without connection and sense: in fact the logical and associating bonds are altogether wanting, and, under the confused medley of disconnected acts and words, the progressive dementia is apparent to the ex- perienced observer. Even to the inexperienced observer the expression of the patients, as well as their random and I/O INSANITY. confused talk, seem the outcome of a silly and childish condition. This variety is known as active or agitated de- incjitia ; it is a sequel of mania and of agitated melancholia, r and is progressive, though o longer duration than passive -^ dementia. Tliis dementia, in which fragments of delusions and de- lusive ideas are still retained, constitutes a transition to that secondary form of chronic insanity which some have called "chronic mania," others, "secondary partial insanity," and which still others have unfortunately classed among the " monomanias." It is observed that some maniacs as well as melancholiacs lose the dominant emotional charac- ter of their insanity, without regaining mental health. The mind, in other words, is no longer stimulated by an emo- tional state to construct expansive or depressive delusions; but, on the other hand, it loses the logical power to correct the delusions formed during the previous period, i.e., the primary insanity. These consequently remain integral parts of the patient's psyche, and become fixed delusions. Unlike the delusions of the monomaniac — which are also fixed — the delusions of secondary insanity ivith confusion of ideas, or " chronic confusional insanity," as the writer proposes to designate this disorder, are not elaborate, not defended with skill and a show of judgment; in short they are not truly systematized. The delusions re- semble ruins left over from the destruction of the more elaborate and multitudinous if less fixed delusions of mania and melancholia, around which the gathering tide of a slowly progressing dementia rises, till the assertion of the delusions becomes a mere parrot-like repetition, and is finally buried under that same levelling sea of dementia which closes the history of all those primary psychoses entering the domain of the secondary deteriorations. The weakening of the logical power and the memory ac- counts for the frequent observation in these patients of a change in their sense of identity. In marked contrast with the primary insanities, the chronic deterioration last mentioned shows few if any anomalies of vegetative life. The appetite and assimi- lation as well as the sleep become normal or nearly so, and not unfrequently the patients become very stout. A rapid increase of the adipose tissues of a patient who is becoming calmer than he was during his primary period of mental disorder is hence, not without justice, looked upon as a sign SENILE DEMENTIA. I/I of evil augury. All recovering maniacs and melancholiacs increase in weight, it is true; but that increase is usually compensatory for the loss of weight occurring at the onset of the disease, and does not as a rule go further. While the general nutrition does not always suffer in the terminal deteriorations, certain trophic disturbances are quite common. Hsematoma auris, cutaneous eruptions, premature grayness, and fatty and fibrous changes of the blood-vessels are frequent accompaniments. These, like the deep structural changes in the nerve-centres, are collateral phenomena, and do not stand in a direct causal relation to the insanity. //. Division of the First Class. Attacking the individuals in Essential Connection with the Development and Involutional Penods. A*^ Senile Dementi.^. Insanity of Pubescence. CHAPTER IX. Senile Dementia. Senile de?nenfia is a progressive, and primary deterioration of the 77iind connected with the period of involution, but exceeding the ordina7-y extetit of such involution to a pathological degree. As stated in the seventh chapter, a certain degree of mental enfeeblement is an ordinary accompaniment of old age, and cannot be considered pathological. Simple diminu- tion of the mental powers, and the intensified conservatism, lethargy, and habits of economy incidental to senility, do not constitute a true insanity, and therefore should not be called dementia. But when the ordinary limits of these conditions are exceeded, when lethargy becomes fatuity, when conservatism becomes suspicion, and penuriousness provokes delusions of attacks on propert}'', the senile sub- ject is the victim of an insanity which' is only found with the aged, and is therefore called senile dementia. Senile dementia is to be considered as an entirely distinct conception from "senile insanity." Senile insanity, so called, includes senile dementia, but senile dementia does 172 INSANITY. not include all of senile insanity. Any form of ordinary insanity, such as mania, melancholia, dementia from active organic disease, and monomania, may be found in the aged, and present at least in the main the features which char- acterize these affections at other periods of life. There is, indeed, no need for discriminating between senile and other periods of life as far as the ordinary forms of insanity are concerned. There is no senile mania any more than there is a middle-age melancholia or an adolescent stupor, and it is best to speak of the ordinary forms of insanity as mania, melancholia, or monomania in a senile subject. The only characteristic form of senile insanity is the one now about to be considered. Senile dementia should not be confounded with other conditions occurring in old age, of which men- tal enfeeblement may be a symptom. There are certain gross organic diseases, affecting the brain in advanced life, which produce a set of symptoms often and improperly classed as senile dementia. Thus, an old person, after a paralytic attack due to haemorrhagic or necrotic brain lesion, may become feeble-minded, forgetful of the proprieties, morbidly irritable, and filthy in his habits. Such a condition is, however, a complication of what is commonly recognized as an ordinary brain disorder, which may produce similar results at any period of life; there is nothing essentially senile in its character, although it is more frequent in the senile state, because the conditions causing it are more com- mon in the aged than in the young. Paralytic and epilepti- form seizures may be accompaniments of senile dementia, but in that case they are epiphenomena, and not essential features of that psychosis; this disorder begins as a senile dementia, and is not secondary to other affections, as are the forms of dementia from coarse organic disease just al- luded to. Senile dementia is to be attributed to a slowly progressing marasmus of the nervous tissues transcending the ordinary degree of intensity; to which more active nutritive changes, in the way of encephalomalacia or haemorrhage may or may not be added. The complicating dementia occurring in old age after coarse disease referred to above, and which is distinct from it, is constantly and characteristically associated with such coarse disease. Senile dementia is manifested by an increased egotism, or by penuriousness, which sometimes reaches such a degree that the millionaire may starve in the midst of his or her mil- lio.ns, and, though residing in a palace, grovel in filth. The SENILE DEMENTIA. 1 73 memory becomes enfeebled, particularly with regard to recent events, while those of an earlier period of life may be well remembered. It thus happens that senile dements frequently lose their way in the streets, do not recognize their own houses and apartments, and cohfound the prop- erty of others with their own. Prejudices are formed on trivial grounds, or on no grounds at all ; and wealthy senile dements have in all ages been made the subjects of speculative and designing persons, to the detriment of their real interests and of tliose who were the subjects of their natural affection in the healthy period of these patients' lives. As the disorder advances the memory continues to decrease ; the incidents of whole years seem to be blotted from the mind; and patients have been known to forget the names and number of their children, or even that they had been married when such was the case. A profound moral deterioration is frequently a marked accompanying feature. Coarse and vulgar expressions are used by persons pre- viously accustomed to select language, or the patient be- comes filthy or intemperate in his habits, and assaults or scolds his children, treating them and the servants like dogs. To this there may be added — particularly in male persons — a pathological sexual desire, a senile satj'riasis, which with some manifests itself in indecent assaults on young girls or even on infants, and with others in absurd and ridiculous marriage plans. While some senile dements exhibit delusions of an am- bitious character — always unsystematized, however — the majority have depressive delusions, and rare instances are on record where senile dements have committed suicide, either in consequence of such delusions, or because they recognized their deteriorating mental condition. The chief and most common delusions of senile dements relate to their property. They suspect that they are being defrauded or robbed ; in consequence they take what they think are the best measures to prevent defraudation and robbery. If their property is in the charge of an agent, they will discharge him and employ another, and another, till they find one who possesses the undesirable qualifica- tions necessary to the management of a senile dement — for experience teaches that intrigants and time-servers have had more success in this direction than straightforward and independent business men or the honest friends of the patient. 174 INSANITY. The anxiety as to the security of their earthly possessions, and their delusions of robbery, produce a lachrymose dis- position and a restless and purposeless activity in these patients. Some of them roam about at night continuously, watching for thieves, while other patients do so without being able to give any reasons for their acts whatever. Others are continually engaged in devising new fastenings for their doors and windows, and. new hiding-places for their treasures. Hallucinations and illusions may compli- cate this phase of senile dementia, and the patients then cry out that they are being murdered, robbed, burned up, cut to pieces, or poisoned. Should no other inter-current illness cut short the course of the psychosis, bed-sores and colliquative diarrhoeas close its history. Sometimes affections of the bladder are very troublesome toward the end of the patient's life, and may lead to fatal cystitis or pyelitis; indeed, incontinence of urine is one of the most constant physical accompaniments of senile dementia from its inception. If the patient lives long enough complete fatuity sets in; he may then become voracious and filthy, to finally die with apoplectiform symp- toms, or with those of a gradual and general paralysis. Aside from a temporary improvement, which is exception- ally observed in those cases where the delusions have a melancholy tinge, the progress of senile dementia is chronic, and consistently in a downward direction. The physical indications of extreme age are always found in senile dementia. The most important of these signs, because it is related to the cerebral condition, is arterial sclerosis; the radials are hard, giving the impression to the finger of a tendinous cord, instead of the normal arterial resilience ; with this the temporals are tortuous. Often there are observable a marked arciis senilis, opacities of the vitreous body, and sometimes cataract, as expressions of a vitiated state of nutrition. An invariable symptom is tremor, but this does not differ in degree from that which is commonly found in very old persons. In certain patients marked h)'peraesthesia has been observed by Giintz,* and vertigo, anorexia, paraparesis, hemiparesis, disturbances of speech, and epileptiform attacks have been recorded in others. It is cases presenting these symptoms, which are associated with more considerable cerebral atrophy and * " Allgemeine Zeitschrift fur Psychia.trie," xxx. INSANITY OF PUBESCENCE. 1 75 •nutritive as well as membranous lesions than the ordinary ones, which have suggested the view that paretic dementia is a pre-senile involution of an active type. Of 2,297 patients whose form of insanity was made the subject of a statistical study by the writer, 82, or a little over three and a half per cent, were classed as cases of senile insanity. With three exceptions these were all senile dements. It may be assumed that the proportion of senile dementia is much greater than the one shown by asylum statistics, as only the agitated and troublesome patients suffering from this malady are sent to asylums. CHAPTER X. Insanity of Pubescence. I7isanity of pubescence is characterized by mental efifeeblement, marked by a silly disposition, following a preliinitiaiy period of depression, ivhich has the same tinge as, tvithout the depth of, that characterizing melancholia, and tvhich coincides with or follows the period of puberty. Probably few persons pass the period of puberty without manifesting some indications of the profound change which the mental organism undergoes at this important physio- logical crisis; a change which in not a few cases is a real change of character, without being for that reason — as those who define insanity as essentially consisting in a " change of character," might be compelled to admit — an in- dication of mental disorder. Particularly in the male sex is the transition between the childish and boyish period preceding, and the adult period following puberty, marked by many comical, ridiculous, and even disgusting conflicts of the boy's nature with that of the coming man. The carelessness, lack of judgment, natural egotism, and sport- ive tendencies of youth are out of harmony with the aspi- rations and feelings which now develop and which are destined to characterize the man. The result of their union is a silly ambition, a mawkish sentimentality, and an obtru- sive self-assertion, which, in a more or less pronounced de- gree, are manifested by most youths; to control which is one of the main objects of every sound educational system, 176 INSANITY. and which in healthy subjects with or without such system are soon corrected by experience through its incidental and beneficial hard knocks. In certain rare cases this correction does not occur; the patients retain the absurd notions, the silly propensities, and the obtrusive egotism of adolescence. Whether it be the existence of a hereditary taint, or masturbation, which weakens the nervous centres, it is certain that the transfor- mation of the childish into the adult character is arrested. This is the essential feature of the hebephrenia of Hecker, the " insanity of pubescence" of Skae and Maudsley. This psychosis begins with a period of sadness; the pa- tients are depressed without being able to assign any rea- son for their sadness, and suicidal attempts are not un- ^f requenL There is, howev'er, no deptli to the depressive emotion as in melancholia, and in the midst of the de- pressed period the patients appear rather obtrusive in com- municating their sufferings to others, and will not hesitate to simulate in order to awaken, not sympathy — which they care little for — but interest! In the midst of these periods they maj^ suddenly burst out in causeless laughter or even joke in a silly manner. In short, the contrast in the char- acter of the changing emotions is great, but the emotions are in no case as deep as in the mania and melancholia of the adult. After this preliminary period the patients exhibit vague or blind propensities; they enter a business, to leave it the next day, wander about aimlessly, or display a stupid malice toward their surroundings. While there is no incoherence the patients manifest a peculiar tendency to adopt verbose language. They will use long words, or such of an odd sound, or ride certain grammatical hobbies. Others will use slang or foreign expressions and quotations by preference. Gradually the condition changes; the intel- lect weakens progressively, and the patient, who is usually a confirmed masturbator, will pass into a terminal dementia marked by occasional furious outbreaks, determined in their occurrence by his unnatural excesses or by powerful exter- nal impressions. Everything connected with the mental state of these pa- tients appears shallow and even unreal. They have sham emotions, sham regrets, sham anger, and sham complaints. Even their hypocrisy, which is a common characteristic, is shallow. In the same breath in which they affect religious INSANITY OF PUBESCENCE. I77 aspirations they will indulge in slangy vituperation, and then break out in causeless laughter. The expression of the countenance is an indication of the condition within; it expresses the leading character of lack of emotional depth, silliness, and insincerity. The course of this form of insanity is protracted. Enfee- blement of the mental faculties is noted from the very be- ginning, and the process may be arrested and remain stationary for years without material progress toward ter- minal dementia. In one case in the writer's experience a relative cure was effected, the disorder early arriving at a standstill, and the positive characters of the illness disap- pearing. But on the whole the prognosis is exceedingly unfavorable. Imperfectly developed cases, such in which the disturbance is limited to a slightly strained emotional condition, with a tendency to writing silly and extravagant poetry, and which appear to be merely instances of a path- ological intensification or undue prolongation of the ordi- nary pubescent state, present better prospects. Pubescent insanity has been observed in but three out of one hundred and eighty-seven private patients by the writer. A computation from the statistics of a pauper asylum yielded the high figure of nearly five per cent of cases of this psychosis. As indicated by its name pubescent insanity is found in subjects between the fifteenth and twenty-second years. Many of the cases are still classed as " primary dementia," particularly when the deterioration is very rapid. Where masturbation is a pronounced feature some writers use the designation " insanity of masturbation." In reality the masturbation, although a frequent accompaniment and per- haps a result of hebephrenia, is not its cause, however much this habit may ultimately modify the character of the psy- chosis. 178 INSANITY. Second Class : Simple Psychoses Associated with Demonstrable Active Organic Changes of the Brain. Dementia Paretica. Dementia Syphilitica. Dementia Organica. Delirium Grave. CHAPTER XI. Paretic Dementia — Preliminary Considerations, There is a form of insanity which, from its constant assoication with the classical symptoms of ordinary organic disease of the brain and spinal cord, merits most attentive consideration. There have been thus far discussed mental affections whose essential characteristics are the mental symptoms proper. We have found that with most of these forms of insanity disturbances of the bodily functions are indeed present; but these are rather attendant and sub- sidiary phenomena, of importance to the speculative so- matic psychologist, than striking features of the insanity. In short, the psychoses thus far considered could be defined and recognized in a crude wa}' without taking into account the coarser bodily conditions; while, with the psychosis we are now about to treat of, this is different. Here the mental symptoms generally present the picture of unsystematized ambitious delusions, combined with progressive paresis and dementia; they may range, however, from atonic depression to the most furious delirium, from the construction of fanciful projects to extreme incohe- rency, and from slight and almost undemonstrable mental impairment to the absolute extinction of higher mental life. In like manner the physical signs, whose combination with these varied mental disturbances is essential to the picture of the disease, may vary from slight disturbances of speech to gross paralysis, or may present themselves under the mask of a posterior spinal sclerosis (locomotor ataxia), of a disseminated organic disease, or of apoplectiform and epilep- PARETIC DEMENTIA. 1 79 tiform seizures. Among the individual signs there may be found almost any and every focal and general symptom known to the neurologist: paresis of various voluntary and involuntary muscles, anaesthesias, paraesthesias, and hyper- aesthesias, pains and trophic disturbances, changes in the vascular tone, amblyopia, hemiopia, color-blindness, and aphasia; not to mention choreiform and athetoid move- ments, progressive muscular atrophy, pseudo-hypertrophic and bulbar paralysis: all these may be found co-existent with the mental disorder, and indeed depending on the same morbid process as the latter. In the case of no other form of insanity are the patho- logical findings so constant and satisfactory. It may be safely asserted that in all advanced cases of this disease a diffuse lesion of the brain, sometimes involving other parts of the central nervous system, is to be looked for. That a disease whose pathological basis is so extensive, affecting numerous centres in varying degree, should present almost every conceivable variation within the outline of symptoms just drawn, is not surprising. That the mental symptoms predominate in one case, the motor in another, and the sensorial in a third; that their order of appearance differs: in some instances, disturbances of vision; in others of speech; in others, absent-mindedness, fits of fury, or hypo- chondrical tcedium vitce opening the history, is perfectly nat- ural in view of the complexity of the functional role of the nervous structures, any one of which may be the first to weaken and break down under the diffuse morbid process of this disease. With the recognition of these facts we may waive any consideration of the mooted question, whether paretic dementia is a simple insanity or a complication of insanity by the features of ordinary central nervous disease. All observers are now agreed in considering this disorder as a primary form of insanity, existing by itself, and they attribute to its physical signs the same value that is as- signed to its mental signs. This disorder is known by a number of names. Some of these are too obsolete to call for mention here, and the designation employed in this treatise is one which is now gaining ground, particularly in England. In Germany it is known as dementia paralytica and ^^progressive Paralyse." These terms are ambiguous, for the dementia sometimes accompanying hemiplegia has been earlier known under the former term; and while the objection is a finical one. yet l80 INSANITY. it has been raised, that the affection is only in very rare instances evenly progressive, being generally marked like that similarly progressive affection, locomotor ataxia, by exacerbations and latent periods.* About two facts there can be no dispute or quibble, that the essential and constant feature of the disease is demen- tia, and that it is associated with paresis of certain muscles. These features are hence incorporated in one term, which is as little ambiguous as it can be made. The only other affections to which the same designation might apply are syphilitic dementia f and dementia from coarse organic disease. Paretic dementia is a very common affection, more frequent in communities whose members are subjected to great mental strain than in those whose members are engaged in mechanical pursuits or are able to indulge in a dolce far niente. Of 2,297 male patients at the pauper insane asylum of New York city, 284,^ or a little over twelve per cent, were paretic dements, or dements with organic diseases. In the same statistics the writer found that the nationalities re- presented by a small quota of the asylum population, such as the Scandinavians, Dutch, Scotch, Italians, and Sclaves, had a larger proportion of their insane among the paretic dements than the nationalities represented by larger num- bers. This excess is attributable to the facts, that the members of wandering professions, such as agents, sailors * Paretic dementia also passes under the names " general paresis," and "general paralysis." The alienist's position with regard to these terms is similar to that above stated as the one held with regard to the use of the adjective "progressive." No scientific alienist will misunderstand the term " general paresis," he will recognize it as a legitimate label for a well-marked affection. But he will abandon its use after being met on the witness-stand, as the writer was in the Gosling case, by an opponent who states, amid the tumultuous applause of the court-room crowd, and the commendatory glances of the "intelligent" jury, that there is no general paralysis except in death. Popularly the disease has been called " softening of the brain," and is diagnosticated and treated as such, and is hence a fruitful field for the charletan to this very day. f Syphilis found as an accessory etiological factor in paretic dementia of the typical kind does not justify the ranging of the case under the head of syphilitic dementia; the latter is a clinically and pathologically distinct affection. X The source of error involved in the confounding of syphilitic and organic dementia is not sufficiently great to affect the proportionate values of these figures. PARETIC DEMENTIA. l8l or firemen on board of steamers, are proportionately num- erous among those of these nationalities arriving at the port of New York; and that exposure to caloric and to syphilis, two potent causes in the etiology of paretic de- mentia, are very common with these professions. The wandering tendency [inaiiia errabunda) of paretics may also account in part for the accumulation of paretics of foreign extraction in this metropolis. Among the five nationalities or races represented in large numbers in the asylum mentioned the proportion of paretic dements was as follows: Anglo-Saxons 13.29 in 100 Celts H.5S in 100 Germans 1 1. 13 in 100 Hebrews 10.29 in i^o Negroes 8.82in 100 It is here seen that the Anglo-Saxon race, the race of the greatest speculative business tendencies, and of a high, if not the highest intellectual development among the races inhabiting the United States, has the largest percentage of paretics. That mere business exertion is not the essential and most fertile cause of the disease is shown by the fact that the Hebrew race, equally as active, and equally if not more successful in the mercantile world, occupies one of the lowest places in the list. That intellectual exertion per se is not a cause, is shown by the lesser percentage among the Germanic races, who have always stood fore- most in the abstract and speculative sciences. Either the high proportion must be directly due to a race predisposi- tion or to some inherent tendency of the race. England and America are the lands of the most active and feverish progress in civilization, of great facilities for rapid travel, of large mercantile and manufacturing establishments, of hurry, bustle, and restlessness generally, and all these feat- ures seem to be implanted in the Anglo-Saxon people. The German, on the other hand, still retains in this land the so-called phlegmatic disposition of his forefathers; the Celt preserves, as a rule, that quality for which he was noted in his native island, of "taking things easier" than the Saxon; and the negro is, as a rule, indifferent and leth- argic in those matters which call for the interest and action of the higher races. The claim that there is a constant re- lation of sexual excesses to the development of paretic de- 1 82 INSANITY. mentia as primary causes, contradicted as it has been by- high authority, is not supported by these figures. No one will claim that the Anglo-Saxon is more libidinous or less able to endure indulgences than the other races. If a re- flection were to be cast on any race in this respect, it would be the negro race — which shows the least percentage of pare- tic dements — to which a libidinous character might be as- signed. When it is borne in mind, too, that where the negro lives under conditions natural to him, and where he is not compelled to enter into competition with a higher race, paretic dementia is almost unknown, the conclu- sion will seem reasonable that paretic dementia is more frequent with races of a high than of a low cerebral organi- zation, because their higher civilization induces a restless mental activity with its attendant emotional strains, and that the disease is hence attributable to the excessive wear and tear of the brain induced by such civilization. A con- firmation of this view is the fact that, while paretic demen- tia is much less common in females than in males, it is most common in those females who have entered into com- petition with the male sex in occupations ordinarily carried on by males.* Paretic dementia, therefore, is not as some have thought a penalty of high cerebral development, but the expression of a discrepancy between the instrument and its purposes; in other words, of the inadequacy of some brains to support the strain to which the race, as a whole, is subjected. It is one of the methods by which the contest for existence is continually being decided in favor of the strong and against the weak; and its greater frequency at the present day is in harmony with the fact, that the con- test for existence, which in earlier epochs was decided on battle-fields and in the arena, is now carried on more large- ly in parliamentary halls, in the bourse, or on " change," and with the pen instead of the sword. That the disease did not exist, however rarely, in ancient times is not demonstrated by the fact that no descriptions recognizable as those of cases of paretic dementia have been handed down to us by the earlier masters of medicine, as is so frequently urged by modern writers. If this rea- son is to stand, then we must assume that a number of disorders, not only of the nervous system, like " spastic paralysis" and " bulbar paralysis," have first appeared within * Excluding the influence of alcohol and syphilis. PARETIC DEMENTIA. 183 a few decades, but that many diseases of a general nature, which patliology lias recognized the existence of onlv within the last few years, have not existed prior to their discovery. The same kind of argumentation would sup- port the view that the planet Uranus was a new creation. It should be borne in mind, too, that many of the statements, made to the effect that paretic dementia is on the increase, are exaggerated, however true the general tenor of this claim undoubtedly is. In many of the asylums in the west of this country the disorder was not recognized in the tables for other reasons than its non-existence; and the widely-circulated error has thus gained ground that the disease, first recognized in the Bloomingdale asylum, is " travelling" from the East to the West. In an asylum like that at Kankakee, in the east of Illinois, which derives its patients from a largely agricultural population, and which is one of the institutions in which a scientific classification has been adopted and is carried out, the proportion of paretic dements given in the tables (6 in 424 patients admitted from 1881-83) is not quite one and a half per cent; but in Chicago,, the metropolis of the same State, the writer is assured by competent correspondents, that it is as frequent in private practice as in New York. Indeed the writer found a toler- ably large number of patients in the pauper asylum of New York city to have acquired their disorder, as they had been born and brought up, in the large cities of the West. It is not safe to venture too far in speculation on the ap- parent fact of a rapid increase of paretic dementia from year to year, made manifest in some statistics.* Where the diagnostic acumen of the medical officers is unques- tioned, as in the large German and French asylums, while an increase is noticeable, it is but a slight one ; in some cities, as in Hamburg, it is actually at a standstill, and in one year at least there appeared to be rather a decrease in this place. But, whatever inferences may be drawn from the imperfect records now at our disposal, there can be no question that *A student of the writer's, himself an asylum physician, visited an asylum in one of the Middle States in which about a fifth of the male and a large proportion of the female inmates were exhibited to him as paretic dements. In many of these cases nothing beyond an emotional tremor of the hands could be advanced to justify the diagnosis, and it seemed that wherever this symptom was discovered, particularly if there were present expansive delusions, no matter whether these were syste- matized or not, the diagnosis of paretic dementia was made. 1 84 INSANITY. one of the great problems with which the preventive medi- cine of the future will have to deal is the grappling sue- cessfully with this scourge of the civilized portion of man- kind. CHAPTER XII. Paretic Dementia, its Course and Symptoms, As indicated in the last chapter, paretic dementia in its full development is characterized by a combination of men- tal and somatic deteriorations. But these constitute merely the permanent and constant background of the disorder, on which we may find developed at various periods of the disease and in bold relief almost all of the main positive symptoms of insanity. It is customary for purposes of con- venience to divide the malady into stages demarcated by these accessory symptoms, and prominent writers on the subject have established three such : a first stage, marked by moral deterioration and other changes of character ; a second, characterized by exalted delusions ; and a third, in which these exalted delusions disappearing, a progressing mental and physical failure closes the history of the disease. Others speak of successive stages of depression, of exal- tation, and of dementia. But while there are a number of cases in which these stages undoubtedly exist, there are a larger number in which they are not sufficiently well marked to justify the discrimination. In a few cases the progress of the disease is even and unmarked by exacer- bations, in others the only noticeable symptoms are a pro- gressing dementia and ataxia with paresis; in some the physical symptoms are prominent from the beginning, in others not; in a few mental deterioration is rapid, in most slow, and in still others it is checked and retrogrades, to ad- vance again. But, however much the disorder may vary with regard to the existence of separate stages, all typical cases have a well-marked prodromal period whose recogni- tion is most important to the general practitioner of med- icine ; for here medical treatment, which is practically powerless in the fully-developed disease, may accomplish a great deal. The Prodromal Period is marked by so insidious a de- PARETIC DEMENTIA. 185 velopment of the symptoms that it is difficult to say anything positive as to its duration. The writer has never seen a typical case in which these symptoms did not cover a period of at least a year. In the majority of patients ob- served in private and consultation practice, and where the relatives had been observant of the approach of the disease, it was determined to have lasted between two and four years. In some it was even of longer duration, and in one case the first outbreak of the illness occurred in 1877, while a pre- liminary change in character, occasional amnesia, purpose- less and unprovoked fits of fury, and hesitation in speech could be traced back to 1856. Morel speaks of patients in whom this incubatory stage may be said to have extended throughout a lifetime. Undoubtedly there are persons whose career is marked by a behavior very similar to that characterizing the paretic dement. Such individuals are full of extravagant projects, they are considered " hail fel- lows well met," being generous to a fault with strangers, though tyrannical and breaking out in causeless fits of anger at home. The most prominent feature of their char- acters is a silly boastfulness, manifesting itself in boyish claims of superior qualifications for almost every and any position in life. In the case of an intelligent merchant in good social standing, whose generally excellent mental training was manifest even in the deteriorating period of his disease, this tendency showed itself in an ambition to acquire physical prowess and to become known as a pugilist. He frequented taverns and other low places of amusement, became an intimate friend of the prize-fighters Heenan and Sayers and, as he paid his way very liberally, was allowed to gain easy victories in the various encounters which he boastfully provoked. Such a "paretic disposition" must not be confounded with another condition, namely, with primary expansive monomania complicated by paretic de- mentia, to which detailed reference will be made later on. (See chapter on Diagnosis.) In that group of paretic dements whose disorder may be designated as being of the "spinal " or ascending type, the symptoms of the prodromal period are such as precede or- ganic disease of the spinal cord, or suggest the existence of an insidious affection of the entire axial portion of the cen- tral nervous system. Pains in the lower extremities, usually described as being of a rheumatoid character, though some- times of the dolorous kind found in locomotor ataxia, dou- 1 86 INSANITY. ble sciatica, early color-blindness, belt-like sensations in various parts of the body, particularly the head, photopsia, tinnitus aurium, and temporary dotible vision are the chief of these symptoms. In the "cerebral" or "descending torm," while these symptoms may coexist in a less prom- inent degree, a change of character is the most notable sign. The careful business man becomes negligent, and the good father or husband indifferent to his family. Fre- quently the patient himself notices this, and becoming mor- bidly emotional, he may weep, or show genuine melancholic depression, because he feels his brain power failing and can- not call up his natural affections as of yore. There is a great similarity between this condition and primary men- tal deterioration. (Chapter VII.) All the mental symptoms of this period are attributable to simple brain failure. The attention is not as readily aroused, and the patient engages in conversation, and after a prolonged harangue of the one speaking to him, inter- rupts him with the exclamation, " What did you say ? I was not listening." This inattention is not the inattention of an abstracted normal mind which is able to recall the sub- ject of its abstracted reverie ; for the paretic, while not hearing what his friend said, cannot tell what he was thinking of that occupied his attention. That faculty has become entirely dormant for the time being, and the pa- retic's abstraction is only a lesser degree of another symp- tom commonly observed at this period, nameh^ a tendency to fall asleep in the middle of the day, in the counting- house, and particularly after meals, or at lectures and en- tertainments. Amnesia is noted from the beginning. At first the failure of the memory relates to trifles; the patient does not recol- lect whether he has wound his watch, and may wind it half a dozen times one day and not at all on the next. He may forget to button his clothes, to pay for his meals at restaurants, or to take his purse with him on leaving the house. More serious omissions and errors are made as the prodromal period progresses : the business man makes wrong entries, or omits to record important items; and the cases of two physicians are related by medical jurists, one having in this period of paretic dementia prescribed i6 gr. of tartar-emetic instead of -^ gr., while the other, a Russian doctor, was sent to Siberia for having caused the death of a colleague by a similar error. In his "empty abstraction" PARETIC DEMENTIA. 187 the patient may take the wrong train, or a car going in the opposite direction to the one he should take ; and is partic- ularly apt to neglect appointments. These acts may be committed by persons normally abstracted, and some of them are habitually committed by those who have failed to cultivate systematic habits ; their diagnostic importance in the case of a paretic dement, therefore, lies solely in the fact that they constitute a persistent change from the pa tient's previous and normal condition. In this stage thefts are very apt to occur, in some cases with a quasi-cx\vci\\\3\ intent ; in others, merely from forget- fulness. Thus a patient will pick up an article to look at it, and then pocket it in his abstraction. Sometimes forgeries are committed with considerable skill by previously upright business men, owing to their loss of moral tone; at other times useless as well as valuable articles are stolen in a stupid and random way. Brierre de Boismont relates the case of an old government officer who for eight years prior to his reception in an asylum had been guilty of repeated abstractions of articles at public sales which he attended officially. His insanity was not suspected until several months before his interdiction. On the occasion of the last theft he was arrested, and Brierre de Boismont examined him. On entering the room this physician immediately saw what kind of a patient he had to deal with; he had the embarrassed pronunciation, " petrified " face, heavy walk, in short, the characteristic signs of paretic dementia. On being interrogated as to the circumstances of his arrest he answered, without the slightest appearance of remorse or shame, " the people who put me in prison are imbeciles, who know nothing of our professional usages; it is the cus- tom among us, a custom known as the ' cote G,' to choose some object of slight value and retain it when taking the inventory, and see, here are two which I thus appro- priated." With this he drew from his pockets a handsome meerschaum pipe and a gold-mounted tobacco pouch. The distinguished physician mentioned pronounced him to be suffering from paretic dementia, and a few months later the patient died of this affection, verifying the opinion.* Simon relates a case, presenting a similar tendency to the manu- * "iiltudes Medico-legales Sur la Perversion des Facult6s Morales et Affectives dans la Periode Prodromique de la Paralysie Generale." Paris, i860. 1 88 INSANITY. facturing of stupid excuses,* at a later period of the disease. A fisherman who, it was subsequently ascertained, had pre- sented signs of paretic dementia for half a 3'ear, was de- tected emptying the nets of others, and appropriating their contents. He was first beaten by the owners, and then taken before court. Here he declared that his oars had become entangled in the nets, and that he had taken the fish out in order to rearrange the nets, intending to replace the former. This explanation was rejected as a "cunning eva- sion," and the physician called in by court pronounced him of sound mind, notwithstanding the fact that the prisoner had been suspected to be — and tlie suspicion was confirmed by witnesses — insane by the police authorities for several months previous. Incidentally to his other declaration, the prisoner announced the characteristic project of running a net across the Elbe River, to be dragged by two steamers, thus intending to catch all the fish at one swoop. Indecent exposures of the person may also be made, in some cases from satyrical motives; in others they are due to the forgetfulness of the patient, who neglects to button his trousers, or fails to bear in mind that he is exposed to the public gaze. It must also be borne in mind that the free determination of the will is gravely impaired in paretic dements. Chorinski, one of the Austrian nobility, was prevailed upon by the Baroness Ebergenyi, his paramour, to poison his wife. A few years later he died a paretic dement. Several instances are on record in which such patients have been induced to marry courtesans or other speculating women, in some instances thereby committing bigamy. The undue influence in such cases has the way prepared by the patient's forgetfulness of the fact of a pre- vious marriage, or his moral deterioration. In this period there is also developed a morbid irritability. The previously sedate and calm head of the famil)'- will fly into a furious passion on hearing of a trifling loss, a slight expense, the breaking of crockery at table, or on finding his meat overdone. The simplest contradiction will cause a fierce denunciation, or even a violent assault. One of the first observed manifestations in one patient under the writ- er's care was the throwing of a large bottle filled with ink at his brother and business partner, on the latter's asking * " Die Gehirnerweichung der Irren" (dementia paralytica). Hamburg, 1871. PARETIC DEMENTIA. 189 him the meaning of a certain entry in the ledger. Impa- tient as the patient is of contradiction, he is impatient in regard to other little matters. One paretic dement, who was turned out of a theatre because he was unable to show his ticket (having in his amnesia forgotten where he put it, or thoughtlessly thrown it away), broke a large pane of glass to climb in b}' another entry. Another, because the atmosphere of a carriage seemed too close for him, and finding some difficulty in opening the window, took his cane and broke out the glass.* With all this irritability in regard to the little affairs of life, the patient is singularly apathetic with reference to more important matters. A patient who threw a knife at the servant, because she took his plate away before he had, as he alleged, finished dining, heard unmoved a few hours later of the collapse of a large business undertaking, which involved a loss to him of over a hundred thousand dollars. It is remarkable how frequently a patient, who has perhaps brutalh^ abused his wife and children for calling in a phy- sician to prescribe for him, on finding that a carriage drive, undertaken at the suggestion of some friend, terminates at the asylum in which he is to be confined, hears the news without manifesting the slightest feeling or making any protest whatever. In one case, the day before the commit- ment, a patient of the writer's had had a physical encounter with an expressman, for leaving one of his trunks on the street instead of immediately carrying it in; on finding himself within the walls of Bloomingdale he walked up to the scales to be weighed with an air of bravado, and said to his companions that they should also avail themselves of the chance of being weighed gratis. Irritability which breaks out on slight provocation is a sign of a weakening of inhibitory power and of a general loss of nerve tone. The reverse of the condition, described by Wundt as the normal one, is hence found in paretic dementia. A healthy person displays a sanguine tempera- ment in regard to the lesser affairs of life, the melancholy temperament in the serious phases of his career, is choleri- cal in connection with events which most deeply affect his interests, and should be immovably phlegmatic in carrying * Both of these patients were brought before juries on a habeas corpus, and these acts were successfully paraded before the laity as rational ones. 190 INSANITY. out his intentions after these are deliberately formed.* The paretic dement, on the contrary, is cholerical with re- gard to the petty affairs of life, phlegmatic at important turning-points in his career, and sanguine with regard to, as well as easily diverted from, the carrying out of his purposes. It is in harmony with the readiness with which paretic dements may be controlled by their surroundings that, under the influence of "jolly companions," they become spendthrifts, while they may be penurious misers at home. And it is an evidence of the frailty of their purposes, and the readiness with which they may be diverted from them, that although many paretic dements develop suicidal inten- tions in their depressive moods, they very rarely carry them out. Simultaneously with the memory, will, and emotional balance, the morals begin to totter. Often moral alienation is the most prominent of the earlier symptoms of the dis- order. Just as the paretic becomes irregular in his habits generally, unpunctual in business hours, and forgets his appointments, he loses sight of the proprieties and of his moral obligations to his family and to society. Just as he becomes careless in the spelling of words, he begins to use improper ones in conversation, employs lewd language be- fore females, and oaths as expletives in ordinary conversa- tion. Sexual and alcoholic excesses are now indulged in. The previously prudent and temperate business man orders cases of wine sent to his office, in order to have the means for indulgence close at hand. The once faithful husband begins amours with the serving-maids before his wife and children, or goes to theatres, to balls, and shows himself in public with notorious courtesans. The accompanying ex- cesses, like the similar ones indulged in by the maniac, pre- cipitate the development of the disease, particularly as an intolerance to alcohol is one of its early and marked feat- ures. A well-meant remonstrance leads to an outbreak of furious violence, the intervention of the police or other authorities to conflicts with the latter, and, the patient's disorder being consequently recognized as a mental trouble, he is perhaps sent to an asylum. This EXPLOSION OF THE ACTIVE PHASE of paretic demen- tia is commonly marked by exacerbations of the physical * " Psychologische Physiologic." PARETIC DEMENTIA. I9I ■signs. The slight defect in the movements of the tongue and lips, hitherto noted only at times, now becomes more permanent. The patient finds it difficult to pronounce par- ticularly the explosive and hissing sounds, and the longer a word containing such sounds is, the more manifest does this difficulty become. In addition the voice changes, be- coming hoarser, and, as Marce claimed, those patients whose disease is due to alcoholic excesses exhibit a more tremu- lous intonation than is ordinary in paretic dements. The speech defect is aggravated by the increasing amnesia of the patient, and he often employs the wrong consonants — ■" b" for " p," or " t " for " d," and " m" for " n." Later on whole syllables are suppressed, and it is difficult to decide how much of the speech disturbance is really ataxic and how much is amnesic in origin. A most characteristic feature is the associationof other and normally unnecessary movements with those of the lips and tongue. The patient, when about to speak, moves the lips as if to fix them more firmly; there is a tremor at the angles of the mouth, an exaggerated and spasmodic movement of the zygomatici, alternate dilatation and contraction of the nostrils, the usually habitual corrugation of the brow increases, and, after all these preparations, the word is thrown out precipi- tately, as if it had had to force its way through some im- pediment. With the speech innervations all the finer motor co-ordi- nations seem to suffer.* The patient's walk becomes less steady and regular. His legs are thrown wider apart to increase the basis of support, and such motions as dancing and skating, et cetera, if among the previous accomplish- ments of the patient, can no longer be executed. The musician forgets his notes and loses the mechanical skill necessary in wielding the bow of the violin, in executing rapid tremolos on the piano, and can no longer regulate the inflation of the cheeks necessary in playing on the brass in- struments. The stenographer becomes unable to follow the speaker whose words he is to report. Watch-makers, engravers, or other mechanical artisans, who depend on the use of their hands, find their occupation more laborious, their attention tiring easily, and their fingers failing them, so that their work is spoiled or clumsily performed. It is * One patient, a ventriloquist, lost his art in the early period of his illness. 192 INSANITY. at this period that the handwriting of the patient may first present the characteristic features to be referred to. The hypochondriacal ideas, depressive moods of the pa- tient, and complaints about head symptoms, if they existed, disappear about this time in the majority of cases. A sub- jective sense of power and general well-being takes their place. The so-called delusions of grandeur then manifest themselves, and are often coupled with morbid projects and extravagant expenditures.* Both the delusions and the resulting projects are unsystematized, and in this respect widely different from those of a monomaniac; they resem- ble the corresponding symptoms of acute maniacal delirium in many features. But it is usually easy for the skilled observer to detect the lacunae in the intelligence behind the veil of delirium in paretic dementia; whereas in the maniac such lacunae do not exist, except temporarily in maniacal frenzy. The latter condition is, therefore, not always distinguishable from the similar phases of paretic dementia. * The distinguished French alienist Brierre de Boismont was called in consultation about the nervous condition of a wealthy man, whose mental disposition had been recognized by the family physician, although the patient dissimulated his infirmity pretty well, under that show of reasoning, specious argumentation, and habitual decorum which is so apt to mislead the laity. The alienist speedily unearthed his prodigious vanity and egotism, and recognizing that the patient was suffering from the prodromal stage of paretic dementia, called the attention of the family to the fact, and advised them to be on their guard as to the dis- posal which he made of his fortune. A year passed without his hearing of the case, when one day the gentleman in question was brought to the asylum, after a scene of violence which nearly cost one of his family her life, and after he had squandered about two hundred thousand francs in absurd speculations. Hammond (General Paralysis of the Insane, with Special Reference to the Case of Abraham Gosling : an address delivered before the Medico- Legal Society, April, 18S0) describes the following characteristic case: " Another undertook the task of buying nearly all the jewelry at Tif- fany's, and only stopped when the proprietors, becoming alarmed, refused to sell him any more. This man took the jewelry he purchased home, and bedecking his wife until she glittered with gems from head to foot, compelled her to walk up and down before him. Then he drew a check for $5,000, and gave it to his servant who returned with a glass of water which he had called for. When I was sent for, the patient told me he was going to Europe. He intended to make the voyage over in the Great Eastern, and would charter the Scotia as a tender. He would pay me $1,000,000 a month, and he would have a corps of physicians on the vessels, the members of which should be attired in a uniform of blue velvet with diamond buttons." PARETIC DEMENTIA. I93 After one of these explosions the patient may become comparatively calm and rational, his physical signs retro- grade, with slight exceptions, and the only remaining men- tal defect may be a feebleness of judgment and a difficulty experienced in sustaining a prolonged mental effort. The relatives of the patient, with whom the wish is father to the thought, and the inexperienced medical adviser may regard him as entirely recovered. But, after a more or less pro- longed lucid or rather para-lucid interval, the patient breaks out in another fit of excitement or depression, and this may recur at irregular intervals; so that the history of many paretic dements is a series of asylum sojourns, sepa- rated by intervals, in which they have been able to attend to their business, or have travelled under the advice of their friends or attendants. But with each attack the patient is left in a more crippled condition bodily and mentally, the resisting power of the brain is gradually weakened, and the patient sinks lower and lower on the down grade to abso- lute dementia. The loss of the finer motor co-ordinations is succeeded by the abolition of the coarser ones; gross speech defects, or absolute aphasia, ataxia of movement and inability to write mark the decline; and when the latter is far advanced, the slight paresis of the earlier period becomes so much intensified that the patient may be unable to leave his bed. The trophic disturbances, which were but faintly indicated at first, as a herpes zoster, for example, also become prominent, and frequent ly terminate the patient's life; malignant bed-sores, fu- runcles, haematoma of the lower bowel, diarrhoea, gastric haemorrhage, or pulmonary gangrene may then supervene. Finally, if the patient escapes or survives these dangers, while the night of utter mental darkness is settling on him, so that he is unable perhaps to utter even the infantile de- lusions of grandeur entertained in the earlier period, he succumbs to apoplectiform or epileptiform seizures of a kind peculiar to paretic dementia, and which may some- times mark the course of this disorder from the begin- ning. Throughout the latter phases of paretic dementia, and aside from the maniacal exacerbations, the patient's de- meanor is marked by good-humored self-satisfaction in the majority of cases. He is consequently generous with his imaginary riches. At the second interview the writer had with a paretic dement, whose disease was a complication of 194 INSANITY. a pre-existing monomania, the patient offered him three (actual) patent-rights as presents. An almost characteristic feature of these patients in their quiet intervals is their enthusiastic and demonstrative greeting of strangers, to whom they will almost invariably state that they are in excellent spirits, and in the best possible condition of bodily health. " Fat and saucy" responded a paretic dement, as he half-stumbled and half-swaggered into the lec- ture-room of the college, when asked how he was getting along; "all right" and "first-rate" are the usual responses in the paretic wards of an asylum. These patients are enthusiastic admirers of anything novel, or which they are unable to understand. When Obersteiner tested a number of lunatics with his " psychodonometer," * while the me- lancholiacs developed ideas of persecution based on the formidable appearance of the instrument, and the terminal dements remained indifferent, the paretic dements were unable to find words extravagant enough to express their unintelligent admiration for the new device. The writer has often found the exhibition and application of the sphygmograph a most useful means for securing an ex- amination of a refractor)' paretic. A brief explanation of the mechanism of some medical appliance, such as the ophthalmoscope, will elicit from such patients the declara- tion that their.doctor is the greatest man in the world — next to themselves of course — he having looked "right into their brains." Quackery which treats these patients as sufferers from " brain-softening" consequently finds an occasional votary here, and the writer has heard no more enthusiastic praises of "static electricity" and similar therapeutical impositions on the credulity of the profession and laity, than from a paretic dement who had been treated by these means. But not all paretic dements are habitually good-humored, self-satisfied, and "hail fellow well met" at this stage of their illness. Some remain ill-natured and distrustful, when they were so before their illness, and many are more demonstrative with the closed fist than the open hand. Any one of the symptoms hurriedly related in the fore- going may be prominent at one or other stage of the dis- ease, absent in a few cases, and appear earlier or later in the histories of different patients. They therefore merit * An instrument for measuring the rapidity of the mental reactions. PARETIC DEMENTIA. I95 detailed consideration before we proceed to consider the varieties of the disease. The unsystematized delusions of paretic dementia have from the time this disease was first recognized been assumed to be always of the expansive kind, and its constant and unvarying features. But this view is erroneous. It is true that such delusions are present at some period of the illness in most patients, but they are of a depressive kind in a few, while in some very exceptional cases no delusions whatever are observed.* When present they are almost pathognomonic. The patient claims to be the most power- ful, the richest and ablest man in his community. He can raise the asylum with his little finger, he has trunks filled with gold in every city in the Union, he is married to all the handsome women in the world, can speak all the living and dead languages, has the best-developed sexual organs ex- tant, and is the intimate friend of every contemporary great man, sometimes himself Napoleon, Caesar, Shakespeare, Grant, Buffalo Bill, and every other celebrity in one person, and the fortunate owner of numerous patents. The follow- ing is a partial list of the *' possessions" of a paretic dement, , who had at one time been a stock-broker in Chicago: Six trunks of gold in Chicago at $30,000 each $ 180,000 Patent watch per year 50,000 Patent knife per year *. . . 75,000 Four trunks of gold at Governor's Island at $16,000. . 64,000 Stock in Chicago 1,200,000 Patent billiard cue per year 15,000 Real estate in Chicago 184,000 Real estate in Washington 90,000 Interest in Chicago 8,000 Interest in Washington 19,000 This patient made at the time few or no errors in his arithmetic and spelling, and was perfectly competent to compute interest; his alleging a larger amount of interest in Washington where he had less property, and his assign- ing different values to his items in different papers show how little reflection and system enter into such delusions * One patient in the writer's experience had advanced far in dementia, paresis, and ataxia, without manifesting a single delusion up to the time when it was deemed advisable to commit him to an asylum. This is the only case observed by the writer which corresponds to the descriptions of paretic dementia without delusion given by recent English writers. 196 INSANITY. as elements. The lack of real originality in the delusions and projects of paretic dements is illustrated by the fact that in this case the " patent knife" had "four blades, one to saw with," the "patent watch" "could go two days with- out being wound up," and the "patent billiard cue" had a "rubber tip." A common day-laborer who attended the writer's clinic, alleging that there was some kind of an animal in his stomach, claimed that the female patients had all remarked the peculiar expression of his eyes, and that he was generally fancied on their account. With an air of greater secrecy he added that his virile member was two feet long and nine inches in diameter, and that he had forty-four houses in New York. In a remission which fol- lowed, the size of the organ in question gradually "dimin- ished;" he admitted that he did not own the houses, but had a lease on them, and later still he claimed no extra allowance, either of real estate or anatomical property, be- yond the ordinary male citizen. Extravagant ideas relating to sexual matters are exceedingly common in male paretics. In females they are less common, and when present usually devoid of the lewd tinge characterizing the sexual ideas of the male; females may claim, for example, that they are pregnant, and delivered every week of a beautiful child, or a child with gold teeth, or some other valuable addenda. These deluspns are as manifold as the number of paretic dements is great, but they have the common characters of extravagance and lack of system. In the later periods they are also exceedingly unstable, and vary greatly from day to day, so that a patient who had ten thousand dollars yesterday claims to have a hundredfold that amount to- day, and to-morrow ma}' find no figures adequate to express his wealth. The general of to-dayis the president to-morrow, and "God above all other gods" the day thereafter. One patient lives in a marble palace in the morning, which be- comes transformed into a golden one by noon, and if a con- versation with him is kept up long enough, his residence will be transformed into diamonds before he gets through. The patient wishes to be whatever he believes to be great and powerful, and his wish is speedily gratified by the enfeebled brain.* * It is an interesting fact, illustrating that the aspirations of the paretic determine his delusions, that the wealthier paretic dements in the writer's private practice have not displayed as extravagant monetary delusions as PARETIC DEMENTIA. I97 Simon aptly says that the position in life of the patient should be borne in mind in estimating the signification of these delusions. Thus the claim of possessing a thousand dollars by a pauper, or of an income of a hundred dollars a week by a common day-laborer, are as grave delusions of grandeur as the belief of having millions, or a daily income of thousands would be on the part of a well-to-do patient. Most patients having such delusions are given to delusive boasting of their past achievements. A Wall Street broker claimed that he had beaten Jay Gould, Vanderbilt, and Russell Sage at every point, time and again. Another boasted of his adventures with wild animals, which he had torn limb from limb in single encounters. The anecdotes of paretics relating to their physical strength are generally embellished by the most brutal and offensive details. Thus one whom the writer took to an asylum, because his rela- tives did not venture to assume the responsibility of accom- panying the powerful and excited patient, related how at a previous asylum sojourn he had seized an attendant, hurled him through the air down eight flights of stairs, and at the bottom of each landing had jumped on his victim, till at the last one the viscera of the latter "squirted " out of the mangled body, and covered the walls and vestibule. The story was of course entirely fictitious; one of the first persons at the asylum whom the patient greeted with cus- tomary paretic hilarity was the alleged victim, and while the account of the " massacre" started with locating the incident at the top floor of the asylum, where the patient had once been, and which was only three stories high, the scene shifted, even while the victim's body was on its way down eight flights of stairs, to the vestibule of his residence, which was four stories high; finally he confounded the past with the present, and made a vigorous pass at the writer, for which he as vigorously apologized. The boasts of a military paretic dement, narrated by Mickle in his instructive trea- tise were yet more extravagant and as cruel. " He said that he was commander-in-chief; that the queen was his mother; that he went with her in a yacht to Russia to see his sister, who was married to the czar; that he with forty comrades killed 10,000 Russians at the Malakoff tower, and the pauper patients at the city asylum. It is in insanity as in health: what the subject has he cares little for; to get what he has not, seems most necessary to his happiness. 198 INSANITY. on the same day stripped the corpses, dug a hole, buried them, and sold their clothing for ^£20." In one case, that of a patient whose disorder dated from an injury by a shell fragment which struck his head at Bull Run, and who boasted of the " boys of Company K," and the gold and guns they had buried at Fort Hamilton, the writer drew out the admission that the patient knew he was boasting; and it seems that sometimes the delusions are merely vague assertions, which have become settled beliefs, owing to the enfeeblement of the logical power, and consequent inability to recognize the absurdit}^ of the boast. The delusions of grandeur are usually associated with EXTRAVAGANT PROJECTS. One patient whom the writer saw at Meynert's clinic, a Hungarian hairdresser, had in- vested his entire fortune in buying up all the hair in the Austrian empire having a certain rare shade of gray. He imagined that this was the color of the empress's hair (which at the time was raven black); that by having the monopoly of the hair required for her artificial curls, etc., he would necessarily become hairdresser to the court; and that his way to future preferment was thus opened. A keeper of a small-beer saloon proposed to build an enor- mous concert-hall in New York, in an out-of-the-way part of the city, and to engage a celebrated prima-donna at a salary of $250 a night to sing there; at the same time he advertised the "Jumbo glass of beer," and scattered five- dollar gold pieces among the street boys. A Cuban pa- tient, who was discharged as " recovered^" from the pauper asylum of the same city, during a partial remission of his illness bought several gross of red and blue pencils to dis- tribute among his fellow patients. Frequently these pa- tients propose to marry all the fine-looking women in a given city, country, or the entire world; one intended to marry a specimen of each race, and another all the women with eyes of a hazel color. Occasionally the patients claim that they are acting under commands from God. They may then order the instant execution of all persons having red hair on account of their antipathy to such, or in more favorable moods and without a cent to their names donate several million dollars to charitable institutions. A de- mented paretic physician* proposed giving a lecture on the * He resumed his practice and continued it for five years, though when seen in the street by the writer showing the characteristic gait of his disease. Since then track of him has been lost. PARETIC DEMENTIA. I99 " Diamond Cross, for the benefit of the Little Sisters of the Poor." For this purpose he was going to hire Steinway Hall and the Academy of Music (distant from each other about two hundred feet), having sold, as he said, ten thou- sand tickets. The incongruity of the paretic's schemes is very well il- lustrated in one of Mickle's cases: the patient ordered " 25^ pounds of tobacco, half a dozen of eau de cologne, four con- certinas, a paper shirt and a paper cravat, 60^ dozen pocket- handkerchiefs, a field-marshal's uniform and baton, 1009 boxes of hams, 26,000 pounds of currants, a stage and a carpenter." To pay for this he gave an order for ;^i5o,ooo, or "more if necessary." One of the writer's patients, who had been prevented from accomplishing a suicidal purpose by his wife, drew diagrams of a tombstone to be erected to his memory, whose inscription recited all his achieve- mento, and sang the praises of his wife for saving the life of so valuable a citizen. Patients having such delusions and entertaining such projects are usually as vain and obtrusive in their demeanor as in their speech and writings. Sometimes the-delusions are absent, but the inflated ideas of self-importance are just as prominent: a subaltern government officer believes the land will go to ruin unless he remains at his post, or a cashier threatens to resign unless his dignity and impor- tance are properly recognized by the directors of a bank. It is characteristic of these patients that there is nothing small about them. Their wives are the handsomest wives, their children the " smartest" children, their friends are all great men, and they have no disposition to bother about such "trifles" as the ordinary daily occupation to which they owe their bread. As already stated, the delusions of paretic dements are not always expansive. Even at the height of the typical disease a sudden change in their character may occur. The patient who was the emperor of the whole world yes- terday is the poorest beggar to-morrow; the God of yes- terday is thrown into the deepest pit of hell to-day; he who was a giant of more than mountain height suddenly shrinks to an invisible dwarf; and another who had the best brains, a stomach that could accommodate tons of the rarest deli- cacies, and boasted of having a most powerful animal frame the night previous, wakes up one morning to the discovery that his brains are running out at his meatus 200 INSANITY. urinarius; that his stomach is gone — the seat of cancer — or gnawed by some wild animal; that his bowels are im- pacted, and that he is as physically weak as he is mentally annihilated. This condition was by the French termed "micromania," so called in contradistinction from the ordi- nary state of delusive grandeur or "megalomania."* It is noteworthy that the delusions of belittlement in pa- retic dementia are as absurd, extravagant, unstable, and un- systematized as those of aggrandizement. While depressive delusions are among the rarer episodes of the fully-developed disease, they are common enough at its earlier stages; indeed, they characterize the "hypo- chondriacal " and depressive forms of the malady, and to some extent are developed in the earlier phases of the dis- ease in most patients. As a consequence of his inability to collect his thoughts and regulate his business affairs such a person alleges that he has ruined or beggared his family, when this is not true; another claims that he is all burned up, that his abdominal cavity is being scraped out inside by some mysterious agency, or is the seat of the ex- ploits of "something alive." Hallucinations of smell of a disgusting character, and " magnetic" or gustatory illusions modify and determine these ideas. Just as suddenly as the extravagant delusion of grandeur may undergo a transition into a depressive one, so the re- verse may occur here. The patient who has been bemoan- ing the ruin of his family all along, some morning may scatter money among the boys on the street; he who was a " worthless wretch, physically and mentally," yesterday, and suspicious of everybody else, fearing that he would be ar- rested and imprisoned, to-day addresses all persons he meets as his best friends, invites them to gorgeous ban- quets, or offers them shares in his extensive mining and railroad undertakings. A patient who could neither eat nor digest, and who had not a penny in the world, accord- ing to his statements made during the hypochondriacal period, awoke one morning with the project to get up a monopoly of the entire sardine and Bermuda onion trade in the world; and having, as he alleged, secured it, pro- posed to eat all the sardines and onions himself. Hallucinations and illusions are much more common in paretic dementia than is ordinarily supposed. Many of * Also applied to expansive monomania. PARETIC DEMENTIA. 20I the delusions are, as has been already hinted, based on faulty sense perceptions, and we consequently find that the hallucinations of an unpleasant character are found in the " micromaniacal" and melancholy phases of the disorder,and those of an exhilarating nature with the ambitious deliria. They are overlooked in paretic dementia as in simple ma- nia, owing to the greater prominence of other symptoms, Mickle,* the first who has systematized the study of these symptoms, believes that at some period of the disease hal- lucinations occur in about one half the cases. He found that visual and olfactor)'' hallucinations were most, and ol- iZ<'<^^C(/C factory hallucinations least common. In the writer's ex- perience auditory hallucinations and illusions were most frequently found, next those of the tactile and visceral sen- sations, then those of sight, and lastly those of smell, the latter in rapidly deteriorating cases. As Mickle says, they " are often variable, unstable, inconsistent, being usually less fixed and systematized than the hallucinations of manv of the insane of other groups." It would be still better to say that they are more like the hallucinations of mania, al- coholism, and melancholia than those of monomania. The patient hears his name whispered or the sounds of ap- proaching footsteps, and sees people with ugly counte- nances making faces at him. In one case in the writer's experience " countless frogs," whose intestines had bulged out from the vent and been "stuffed into their mouths," " hopped around" the patient. Ver}^ frequent are the visions of heaps of putrefying corpses, which are often associated with corresponding hallucinations of smell. Sometimes voices are heard commanding the patient to do a certain deed; in an impure case, one of traumatic paretic dementia complicating an undetermined pre-existing mental disor- der, the patient heard voices commanding him to kill some one, in order that he might himself be compelled to com- mit suicide. According to Mickle, hallucinations and illusions of the sense of touch are manifested as ''faecal lumps adhering to the skin, or dirty fluids thrown upon it," and the illusions of the sense of touch generally are apt to be of a disagree- able nature. In one case of the writer's, that of an aged paretic dement who had advanced spinal lesions, vermin were complained of, which he alleged the superintendent * Journal of Mental Science, October, i88i, and April, 1882. 202 INSANITY. had bred to annoy him. On admission several scabs were found in his vest pocket, which he carried with him as an antidote to similar inflictions, which he said were imposed on him before his admission. More frequent are the sense disturbances of a pleasurable kind. The wall-paper of the patient's room is changed to gold, his furniture to dia- monds, worthless rags and scraps of paper are hundred- dollar bills, and pebbles and fragments of glass are diamonds. Often the patient sits in a corner, in rapt ec- stacy over the kaleidoscopic visions of heavenly and mili- tary pageants doing him honor. In the writer's experience unpleasant hallucinations in- volving a multiplicity and sameness of objects are indica- tive of a rapid progress of the disease. In one of the most acute cases observed, that of a young man aged twenty- two, lights were seen everywhere: torch-light processions across the island on which the asylum was situated; boats on the river covered with torch-bearing soldiers; and whole regiments carrying lampions, and intending to march against the patient, were awaiting transportation across on the opposite shore. Disturbances OF THE SPECIAL senses and visceral inner- vations are found aside from those just mentioned. Many paretics become amblyopic,* in consequence of central pro- cesses or affections of the optic nerve. Others suffer from per- manent or temporary hemianopsia, due-to cortical disease or dropsical distension of the third ventricle. Loss of smell (anosmia) is occasionally observed early in the disease, and becomes usually marked as the morbid condition progresses. Voisin is decidedly in error in claiming that it is a constant symptom in the early stages, and not a single writer agrees with him on this head. An insatiable craving for food (bulimia), which is noted particularly in patients with con- siderable deterioration, is attributable to a disturbance of the vagus nerve; v/hile anaesthesia, parsesthesia, hyper- £esthesia, analgesia, or hyperalgesia, are noted in those cases in which the spinal disease is prominent, and they some- times serve as the basis of illusional delusions. Thus one of Mickle's patients believed that his skin was tucked in. * In a will-contest, the Perrin case, tried in a Western State, sclerotic degeneration of an entire occipital lobe was reported by the pathologist witness, and it was singularly enough omitted to bring this fact into con- nection with the amblyopia noted during the decedent's life. PARETIC DEMENTIA. 203 another that it was hung up to dry, and a patient of the writer's was continually picking off "gold leaf" from his bodily surface. The EPISODICAL ATTACKS of paretic dementia are among its most important signs. They are of three kinds, which, from their resemblance to maniacal delirium, epileptic fits, and apoplectic seizures, are called respectively the maniacal, epileptiform, and apoplectiform attacks of paretic dementia. The nature of the maniacal attacks of paretic dementia varies with the period at which they appear; for, like the other episodial outbreaks, they may mark the disease at an earlier or a later period, in rare cases recur from the begin- ning to the end, and in still rarer cases be absent altogether. It is evident that in the earlier periods before the mind has undergone deep decay, the deliria must be more creative, the flight of ideas more extensive, and a chain of reasoning occasionally visible in the patient's words; while in later periods the fancies of the sufferer will be hampered by the dementia, their expression checked by aphasia, and reasoning impossible, because its essential foundation, the memory, is grossly impaired, and the association of ideas interrupted. Meschede reports a case of a paretic who, brought to the asylum early in the disease, suffered from a maniacal attack of three hours' duration, in which the flight of ideas and rapidity of speech were actually delirious. He did not interrupt the torrent of sentences which issued from him but once or twice, to moisten his parched lips with a little water, and all this time announced his scheme to measure the orbits of the planets, thought he was determining the distance of the dog-star, undertook to square the circle, and finally gave a feast to the whole world of truly Arabian Night's profusion. There are a few cases on record where this maniacal condition continued for a long period, or even marked the entire course of the disease. Such cases terminate rapidly through maniacal exhaustion or other complications, and have been desig- nated galloping paretic dementia. In others there is a sub- acute maniacal condition, analogous to hypomania (p. 136); the patients then are not actually delirious, but display a restless activity, often leading them to the performance of boyish and silly acts, such as dressing themselves up as women. A noted pantomime actor examined by Hammond first manifested his disease bv hurling loaves of bread, turnips, cabbages, and other objects employed in the pan- 204 . INSANITY. tomime among the audience, and later by uniforming a number of children in " Humpty Dumpty " costume, intend- ing to teach them his art, and thus to perpetuate it. Just as this analogue of the milder attacks of mania is found in this protean disease, so the severe attacks of maniacal furor are also and more faithfully copied in it. The furor of the paretic dement is one of the most fearful of all the occur- rences of the asylum ward. Day and night these patients rave, tearing and breaking everything within reach, besmear themselves with their excrement, or even devour it, and shout at the top of their voices. They yell alternately that they are being murdered, that they wish to get out, an- nounce the most extravagant delusions, claiming that they have millions on millions of palaces, all the wealth of the world, can lift the solar system with a finger, or threaten their attendants with the vilest and most cruel punish- ments. The brutality of these patients is something re- markable. It is the possibility of the maniacal attacks oc- curring, and the great likelihood of their leading to vio- lent and fatal assaults, that should be borne in mind by those who let loose such patients on society in the remis- sions of the disease. The attacks of paretic furor last a few hours, days, and occasionally weeks, and may cause the death of the patient by exhaustion; particularly when they recur in rapid suc- cession. It is remarkable to what extent the dementia and certain physical signs of this disease may be masked by these attacks. The furious paretic dement has a more ex- tensive vocabular}^ more expansive ideation, less ataxia and aphasia than he had during the previous period; and one who previously was bed-ridden, or tottered about the wards with the characteristic paretic stagger, now steps more firmly and destroys heavy doors and furniture. One night the writer was suddenly called to the residence of a de- mented paretic patient, and in the absence of conveyances and assistance was compelled to stay up with him until the morning. A heavy blow was the first greeting, but a little art elicited a characteristically profuse apology from the patient. An hour before, he had broken the panels and driven a heavy door from its hinges with the intention of murdering his wife, in whose behalf he subsequently em- ployed the writer's medical services, and, to satisfy a sim- ulated hysterical desire of hers, tasted the medicine she was to receive, thus taking what was really intended for PARETIC DEMENTIA. 20$ him. He had attempted to set fire to his house three times that night. Subsequently his delirium, which toward morning became modified and diminished by the conium and hyoscyamus given, assumed a less destructive and more expansive character. The patient went over his school attainments and almost every boyhood reminiscence and event of his life, in an incredibly rapid speech which lasted eight hours, and was occasionally marked by quite poetic flights. In some cases the maniacal explosions are followed by stupor or aphasia, and complicated by the attacks to be next considered. The EPILEPTIFORM SEIZURES may, as already indicated, take place at any period of the disease, though usually observed only near its termination. In the following case they were the first symptoms noted, and had — what is very rarely the case — the true epileptic character : A porter in a down-town warehouse had been promoted to a higher position, greater responsibilities and labors of a mental character were thrown on him; in the midst of apparent health, having been slightly " worried," he was seized with a convulsion lasting several hours, with partial consciousness, and later on these convulsions occurred in status-like succession, at intervals of a week, for some months. Eighteen months after, the convulsions having been absent for a year, he died with the "quiet type" of paretic dementia. In another now under observation a re- mission of over eight months followed a series of such at- tacks. In ordinary cases these attacks occur after motor paresis is already indicated, and begin as imperfect fits of the clonic kind, aft'ecting the muscles of the face, or of both the face and arm, on one, or more rarely on both sides. The spasms are not usually as violent nor as excursive as those of epilepsy, and in many instances, particularly in those onsets which last for whole days, resemble a convulsive tremor rather than an epileptic fit; consciousness is impaire d or not nota- bly affected; at times, however, an initial spasm of a tonic kmd is observed, and then there may be well-marked con- vulsive action of all the muscles of one half of the body and conjugated deviation of the eyes and head with abolition of consciousness. The appearance of a patient lying for many days in a continued convulsion involving all the muscles of one half of the body with conjugated deviation is one of the 206 INSANITY. most surprising ones experienced by the novice in an asy- lum. And still more surprising is the frequent recovery of the patient from so formidably appearing an attack. Apoplectiform seizures may, like the epileptiform ones, inaugurate the disease in exceptional cases. Ordinarily their appearance is heralded by " congestive spells." The patient having for some weeks observed that his head feels heavy and dull, or as if a tight band encompassed it, after an unusually liberal meal or a slight indulgence in alco- holic beverages, experiences a sudden rush of blood to the head; his face becomes crimson or purple, the temporals throb violently, and for a moment there is an inability to speak or to collect the thoughts.* These attacks may occur in the midst of conversation, and while the continu- ity of ideas is interrupted by them, the thread of thought is resumed when the normal or approximately normal con- dition of the circulation is re-established. They are but momentary; the more severe ones resemble the apoplex- ies f due to extensive cerebral haemorrhages, and are of longer duration. Here the patient may suddenly fall down as if struck by lightning, and the entire half of the body may then be found limp and removed from the influence of the will, or but imperfectly controlled by it. These apo- plectiform attacks may be complicated by convulsions, by tetantic spasms, moinemcnts en manege, and, as Kiernan was the first to notice (1S76) in a case shown the writer, by athetoid motions. It is not the least remarkable feature of the strange disease we are considering that these at- tacks, like the epileptiform seizures, are often and rapidly recovered from, as far as the life of the patient and gross motilit)' are concerned. The effect of the epileptiform and apoplectiform episodes on the patient's general condition is disastrous. Occurring as they often do during the remissions, just at the moment W'hen the patient has been apparently improving, and leav- ing him more or less enfeebled or aphasic and paralyzed, they destroy what little hope as to a delay in the progress of the disease may have existed. Although no invariable rule can be framed it may be as- * A condition which is a pathological imitation of the action of nitrite of amyl. f True apoplectic attacks dependent on haemorrhage do occur in the terminal stages. Such were determined at \!a.^ post mortem of three of the writer's cases. PARETIC DEMENTIA. 20/ sumed that those paretic patients wlio experienced numer- ous syncopt4€ or vertiginous attacks in the prodromal period of their disease, as many do, will be more likely to suf- fer from epileptiform, and those who had chiefly congestive spells and " word-stoppages" will have apoplectiform seiz- ures toward the end of their lives. Both classes of attacks may however be, and frequently are, associated in the same patient. Among the continuous motor disturbances of paretic de- mentia those of the pupil merit special consideration. Its most characteristic condition in this disease is inequality, •due to paresis of the circular fibres of the iris of one eye, or to a greater degree of paresis of the iris of the side where the pupil is relatively dilated. Although Lasegue could •only find such a difference in one third and Simon in one half of his cases, the writer is inclined to believe that, on com- paring — not a large number of patients simultaneously — but their records extending over the entire history of the disease, this inequality will be found to have been present in the majority of paretic dements at some time or other. The inequality is usually not constant; one week the pupil of the right, the next that of the left eye may be the nar- rowest, and in exceptional cases bilateral dilatation may alternate with bilateral pin-hole contraction. In some cases extreme pin-hole contraction is noted from the beginning; these run a rapid course,* but not, according to the writer's observations, because pachymeningitis is apt to be present under these circumstances, as Simon claims. In one patient, whose commital to an asylum was made the subject of litigation, maximal and symmetrical dilatation, with normal contraction under the influence of light and efforts at accommodation, were found. His symptoms were of the typical kind; while Simon, who observed a similar condition, found his patient to have symptoms resembling those of apathetic melancholia. An extreme dilatation of both pupils following pin-hole contraction is an indication of rapid decline, and is accom- panied by oedema or other trophic disturbance. It would be hardly necessary to refer here to the opinion of Austin — that the left pupil is more frequently dilated in * Particularly if the contour of the pupil is not round but irregular — a condition which must be distinguished from the residual irregularity following syphilitic iritis, a not uncommon condition in paretic dements. 208 INSANITY. paretic dements having exuberant ideas, and the right in those with depressive ideas — if it were not for the fortu- nately isolated attempt which a recent writer on the disease made to resuscitate this exploded — not to say a priori ab- surd and extravagant view — by certain statistics which happen to answer themselves.* The pupil is found to have the characteristic features known as the " Argyle Robertson pupil " in those cases where the spinal symptoms are well marked and ataxia or abolished tendon reflex and other evidences of posterior sclerosis are early signs. This symptom is not as frequent in paretic dementia as has been claimed by some recent writers. It is not necessary to refer here in detail to the signs ac- companying the organic affections of the cord sometimes found in paretic dements, or to the signs of focal hemi- spheral lesion which are its frequent accompaniments. The * Austin (" On General Paralysis." London, 1859) says: "When the right pupil has been the more affected \.\\& general tone of the delusions has been more melancholic, and with a more implicated left pupil, their usual complexion has been elated, and their coloring gorgeous." (Italics Aus- tin's.) Pelman and Nasse took the trouble to demonstrate the untena- bility of this view, but no one succeeds better than the writer referred to in the text, who, in thebelief that he is supporting Austin, says: " From an examination of eighty cases in the asylum in which there was a per- ceptible tendency in one or the other direction, it would appear as if there was something in the theory, for in the melancholic cases the left pupil was the more dilated in thirty and the less in only eight; while of the maniacal the right was the larger in thirty-three, and the left in but nine." ("General Paresis," by A. E. Macdonald, M.D., ^4;;/. y^//;- .^t/" Insanity, April, 1S77.) A comparison of the respective statistics furnishes the most sinister disproval which any theory has ever experienced, and also constitutes a significant commentary on the reliability of certain pamphlets. Austin's figures are cited from his table on p. 36. Number of paretics with pronounced elation or depres- sion. he'" C u 'Si! f «■-£? •S c'5. g 3 1"" 41— bxi >-5 y CTlT ^ •5 c'H. s *. a. rtrS ■SO. c 1:2 III 3 « 4) Ac u.2-2 4> M-- 6 u 3 3 o.a -Cm I. .2 3 Q.O. 4) nl •a 3 c n. u «' 4i"u;r3 ■Omo. B S 3 §0.0. Austin's fig- ures 64 1 15 s 39 I 3 His support- er's figures. 80 33 9 -8 1 30 PARETIC DEMENTIA. 209 attempt to do justice to these themes would necessitate the extending this chapter to the dimensions of a volume. Among the motor disturbances those of the facial mus- cles, the hands, and tongue are of the greatest diagnos- tic importance; in fact, the expressions of the paretic's face, like his speech, are the most prominent, constant, and char- acteristic physical indications of his disease. The prodromal period is not always marked by a perma- nent disturbance of the facial and lingual innervations. There is less of the normal play of the features, or it is ex- aggerated owing to a slight ataxia: usually fibrillary tremors accompany the more pronounced changes of expression, particularly when the patient is excited.* With this the explosive opening of spoken sentences referred to in the earlier part of the chapter may be occasionally observed, and it increases after the various exacerbations and para- lytic episodes of the disease, being particularly marked with the consonants requiring labial apposition and lingual firmness. The patient, like an intoxicated person, finds it difficult or impossible to say " truly rural," or " Peregrine Pickle," and will instead say t-t-t-tooly roodal — t-t-t-trural roo-roo-roodial. " Emotional tremor," as it is called, is also frequently noted. The patient, when about to speak or when suddenly accosted, is seen to have a fine tremor of the lips, particularly marked about the angles of the mouth, as if he were about to break out in sobs. But there^ is no real emotional state; the patietit may be extravagantly hi- larious at the time, and the designation is a misnomer,f for this tremor is an ataxic associated movement and should be designated "paretic" or "ataxic tremor." As the disease progresses all these symptoms become in- tensified; a variable degree of ptosis, or drooping of the upper eyelid, is noted, and the features generally are coarser and finally become obliterated altogether. A characteristic element of the facial expression in advanced paretic de- mentia is a tonic contraction of the corrugator supercilii * The " Nachbewegungen" and " Mitbewegungen" of the Germansare very commonly observed. f There is sometimes observed very early in the disease a morbid pseudo-emotional condition. The patient experiences the expression of emotions without a corresponding emotional state ; reminiscences of a pleasant character, for example, are accompanied by choking sensations in the throat and a flow of tears, while those of an opposite kind may be associated with a vacant smile. 210 INSANITY. and the occipito frontalis. Probably this action is at first a sort of automatic equipoise for the paralysis of the levator palpebrae, and then becomes habitual; for it is most marked in those cases where the ptosis is extreme, and on that side of the face where the latter is most pronounced. The fine tremor of the lips becomes coarser, and fibrillary twitches of thezygo- matici, the levator labii superioris, and particularly of the muscles of the tongue, which may have been only occasional occurrences in the earlier periods, now become constant. A pronounced coarse tremor is observed in the hand on or- dering the patient to stretch it out while spreading the fingers; and the handwriting, which shows at first only a similar tremor, degenerates to scrawling, and the deviations from straight lines are more considerable. The patient fre- quently erases or blots his words, and a most constant feat- ure is a gradual deterioration of the handwriting in lengthy documents; the patient begins a letter very fairly, but, as he goes on, the words are formed more irregularly, and finally he is unable to keep on the line, writes above or below it, but usually runs obliquely down across the page. While the opening of the letter may be, aside from the tremor, written in a good business hand, the signature may be illeg- ible, a mere scrawl, or a blot. The omission of words, the meaningless repetition of whole sentences, the doubling of single and the reduction of double consonants are among the features of more strictly psychical origin which serve to characterize the documents of paretic dements. Of these such patients usually carry a quantity in their pockets, and many of them exhibit a stupid letter-writing tendency which in less educated ones is replaced by as empty a word diarrhoea. The other co-ordinated movements of the hands suffer with the writing. The patient who, if a mechanic, first no- ticed an inability to carry out his finer manual work, now becomes unable to button his clothes, or, in extreme cases, to carry a spoon to his mouth without spilling its contents. In the lower extremities the motor disorder manifests it- self, as a rule, in a combination of paraparesis and ataxia, whose characters will vary according as the lesion of the cord or that of the brain preponderates; for symptoms hav- ing a superficial resemblance may be due to lesions in either localit}^ contrary to the general belief. It is exceptional to find typical locomotor ataxia in pa- retic dementia; there is usually less of the throwing out of PARETIC DEMENTIA. 211 the leg and bringing down of the heel, and much less sway- ing on the patient shutting his eyes,* and equally less un- certainty on walking in the dark. In advanced cases the legs are dragged along the floor, often unequally so, giving the impression of a halt or limp, the chief movement of the extremity is at the hip joint, the knees being stiff and the patient consequently sways to and fro in walking. Finally — scarcely able to lift his leg from the ground, stumbling over his feet — while announcing the project to walk around the world in twenty days, or " to take the belt from Rowell," the patient is compelled to take to his bed. It is remark- able how, in testing the resisting power of the muscles when the patient is in bed, these may be found quite powerful, albeit the patient is unable to walk. This discrepancy is to be explained on different grounds from that observed in locomotor ataxia. A very important motor disturbance in paretic dementia is that of the muscles of deglutition and phonation. How much of this is really an ataxic disorder the writer is un- able to determine; though it is to be supposed, in view of the anaesthesia of the larynx and pharynx observed in sev- eral cases, that a sensory disturbance may enter as an ele- ment into the dysphagia so frequently noted. The patient is very often suffocated by a bolus of food, and more than once has the tube of the stomach-pump been passed into the larynx and trachea without any of the usual indications of this accident on the part of the patient. It is difficult to determine the precise extent and charac- ter of the numerous sensory disorders in paretic dementia, owing to the inattention and dementia of the patients. These signs will therefore never have the diagnostic impor- tance which the other symptoms have, and we may there- fore pass by them with this reference. Disturbances of the bladder and the renal excretion are frequently observed in paretic dements. Aside from the episodial albuminuria, reported by various observers as a sequel of the apoplectiform attacks, and such rare phenomena as haematuria (noted in one case within the writer's experience), cystitis, and pyo- nephritis are common occurrences toward the close of the disease, and often end the patient's life. The more marked the spinal lesion the * Commonly there is a decided unsteadiness in standing with the eyes- open, which is not greatly increased by closing them. 212 INSANITY. earlier will paresis of the bladder and its attendant phe- nomena appear. There are cases, however, in which the urinary secretion does not present any anomalies whatever, nearly to the last moment, and then they may be the distant result of over-distension of the bladder through the amnesic neglect of the patient. The Vaso-motor and trophic disturbances of paretic DEMENTIA are among the most interesting and striking symptoms of its later stages. Early disturbances of a vaso- motor nature are the flushings of the head after meals, and the similar spells which herald the apoplectiform and epileptiform attacks already desci'ibed.* Anomalies of the body temperature have also been claimed to exist at vari- ous periods, but the evidence on this point is still ver}?^ con- tradictory, and the writer's own observations, made some years ago in conjunction with Dr. Kiernan, were not suffi- ciently systematized to be of value except with regard to two points : In the first place, those patients who, compar- atively bright and active in the morning, deteriorated through the day, becoming listless, stupid, and having to be taken to bed in the afternoon, were found to have no rise in temperature, and in a few cases a fall of nearly a "degree (Fahrenheit) toward evening. In the second place, a rise in temperature amounting to between one and five degrees, f more marked in severe than in mild cases, was noted to occur after the apoplectiform attacks, and to grad- ually decrease with recovery or death. On the whole, how- ever, and particularly in the earlier periods of the disease, the revelations of the thermometer are not constant nor pathognomonic. The PULSE in the early stages reveals very high tension in the active forms of the disease; in a large number of patients it is normal, and in the depressive forms the writer has found unusually low tension in several cases. The "plateau" at the summit, claimed by Voisin even for the early period, is found only in these cases and toward the end of the dis- ease, when there is marked cardiac enfeeblement; it then does not differ from the flattening of the percussion apex found in other forms of dementia. The revelations of the *In the prodromal period of the disease the writer has found remark- able and undoubtedly pathological variations of the surface temperati/7-e particularly of the hands and forehead, it being very high after meals and rhental strain. f Fatal termination. PARETIC DEMENTIA. 213 sphygmograph, like those of the thermometer in paretic dementia are of high scientific but not of any great diag- nostic value, except indirectly in this way: there is often — and in advanced cases constantly — found an irregular and coarsely wavy character of the line of descent, which is the expression of the irregular muscular tremor of this disease. Among the more important vaso-motor disorders are the changes in the bones, gangrene of the lung, and the malig- nant bed-sore. The former,* like the othaematomata some- times found in advanced paretic dementia, have been referred to in Chapter X. The gangrene of the lungs found in paretic dementia may be due to septic absorption from bed-sores, to the passing of food into the trachea and bronchi, and, finally, it may result from central processes, developing in numerous foci with the apoplectiform attacks, and probably in a man- ner analogous to the multilocular pulmonary lesions found after ordinar}'' cerebral hemorrhage. Decubitus is common in paretic dements who are bed- ridden; but there is a kind of bed-sore which is not due to pressure or to maceration by urine like the ordinary variety, and which develops particularly after the apoplectiform attacks. It begins as an erythematous spot of a purplish color, on which vesicles appear, after whose bursting the livid surface of a deep tissue infiltration becomes visible. This latter rapidly undergoes necrosis, and the destructive process may extend so deep as to involve the sacrum and reach the spinal canal. f This is one of the most furibund of the complications of paretic dementia; ar\d\\i& malig/iajit bed- sore, as it is properly called, may develop in a few days and * In paretic dementia with pronounced posterior sclerosis the joint and bone chantj^es found with that disease may be observed. f At the thirty-eighth meeting of the " Berliner Psychiatrischer Verein," Dr. C. Reinhard reported a case of a female paretic, in whom numerous microparasites (microsporon septicum) were found in the nerve-centres, with septic cerebro spinal leptomeningitis. These lesions were due to septic invasion by way of the intervertebral openings and the cerebro- spinal fluid from a decubitus. It is not necessary to refer here in detail to certain pathological curi- osities, such as Addison's disease (observed in one case), mottling of the skin, exophthalmus (in one dispensary and in one asylum patient), pemphigus, purpura, unilateral sweats, spontaneous gangrene, hae- morrhage in the stomach, rhinhsematoma and haematoma of the lower bowel, which, with other trophic disturbances too numerous to mention, are occasionally found, though not characteristic of the disease. 214 INSANITY. run a fatal course in a week. Sometimes several of these sores appear simultaneously in large numbers, at the troch- anters, heels, occiput, and elbows; and their rapid develop- ment, the absence of the ordinary causes, and the fact that they chiefly appear after the apoplectiform attacks, justify us in considering them to be of trophic origin. Varieties of Paretic Dementia. — Most modern authors make a number of subdivisions of this disease. Some years ago the writer* differentiated from the typical variety, in which the prodromal symptoms are mental and are followed by disturbances of the eyeball, face, tongue, and pharynx movements, and which appears to be a " descending" affec- tion, that form in which the mental symptoms appear after serious evidences of a spinal or axial affection of the nervous system have been observed, and which may be classed as an ascending affection. f There is no necessity for making any further subdivisions. Some cases, as al- read}'^ mentioned, run a "galloping" course, others are evenly progressive (the so-called quiet cases), and most are marked by remissions. The remissions of paretic dementia merit our special at- tention. Countless have been the errors made by those who have looked on these hiati in the disease as recoveries. There is no more remarkable and deceptive observation in neuropathology than the abatement of a dementia with delusions of grandeur, which permits the patient to return to his vocation, and the simultaneous disappearance of a paralysis and ataxia, whicli may have been complicated by episodes of an almost fatal character. Although residua of the symptoms may mark the period of remission, yet there are exceptional cases where even the expert may be * Psychological Pathology of Progressive Paresis, Journal of Nervous and Mental Diseases, 1877. f At the time the writer was unable to separate a series of cases, in which there was a quiet progressive dementia, with progressive paresis, ataxia, and epileptiform episodes, from typical paretic dementia, although aware that the lesion which produced this combination was a peculiarly distributed multiple sclerosis. The opinion of authorities generally is to the effect that these cases, like certain clinically similar ones of cerebral syphilis, should not be included in paretic dementia. The question, however, is still stib judice whether there is not every connecting link between these various affections, and it is greatly complicated by the fact that undoubted paretic dementia is found in numerous syphilitic sub- jects on the one hand, while there is a special form of syphilitic mental disorder on the other. PARETIC DEMENTIA. 21$ unable to detect any deviation from the standard of mental and physical health. In the vast majority of cases, however, tremor of the hands, inequality of the pupils — if it previously existed — and a slight speech defect and clumsy walk are found more or less prominent even in the remissions. An anomaly of the moral or mental character, or of both, is also quite common. The patient is given to purposeless lying, is irritable and extravagant; to the expert the con- tinuing dementia is but imperfectly masked by the super- ficial signs of recovery;* while to the laity the occurrence of an assault, the expenditure of a fortune, or an apoplecti- form attack, may prove tragical or costly comments on their ready credulity. Oddities of behavior not previously noted in the patient may characterize the remission. One of the writer's patients would stop before every looking-glass, manipulating his side-whiskers whenever he thought he was not observed. Another became an active politician and controversialist, although in his sane period he had a great contempt for the political career and the general complexion of politics. These remissions may last from weeks to years; their average duration is from two to four months. Lionet and Taliet agree in believing that they are more perfect in the congestive variety. In one case in the writer's observation, which has since been rapidly running a downward course, the remission lasted three years, during which time the patient attended to extensive commercial undertakings with fair success, and took charge of several assignments. Such remissions may be regarded as constituting a transi- tion to a genuine recovery, and are particularly frequent with " alcoholic" paretics. Although the prognosis of paretic dementia is almost un- qualifiedly bad, and most of the cases reported as recovered have subsequently relapsed, yet there are a few well-authen- ticated instances where the history of the patient has been traced for five and six years after his last asylum discharge, and he has not given the slightest indication of a relapse in that time. The writer met such a patient, in whose case there had been a rheumatic etiology, and who had had a typical * Morel aptly says, that when the patient, however well he may carry on certain routine duties, retains the stolid expression, the stony stare, and the corrugated forehead of paretic dementia, he is not cured, but that his disease is progressing under the " mask of a remission." 2l6 INSANITY. outbreak, five years after his discharge, and was unable to find any indication of paretic dementia in him. A remark- able and rather comical instance occurred in Austria: a pare- tic dement escaped ixoxci. the asylum, and five years later paid a visit to the authorities to demonstrate his recovery. Gau- ster* and Flemmingf have also reported several undoubt- ed cases of recovery; and, in a case of Schule's,J restitutio ad integrum even occurred after an apoplectiform attack. An observation is cited by Simon from Ferrus of a patient recovering and remaining free from the disease for twenty- five years, while Baillarger, Bayle, Calmeil, and Sutherland report others where the patients' histories were followed up for from six to ten years after their discharge, and no relapse occurred. Baillarger himself questioned whether these were genuine cases of paretic dementia; and more recent observers believe that they were of the syphilitic, alcoholic, or rheumatic varieties in which cases the prog- nosis is relatively better. The duration of the disease as a whole is variable. It has been already stated that the prodromal period may last only a few months, usually a few years, and in rare cases nearly a lifetime. Dating from the explosion of the malady the lethal termination may occur in six months,, more commonly in three years; and, in not a small number of instances, in six or ten or even more years.§ Paretic dementia usually develops in patients between the thirtieth and fortieth years; it has been exceptionally observed in very aged individuals, and occurred in patients over sixty, in five out of three hundred and forty-six cases observed by the writer. The youngest paretic dement ob- served in this series was aged eighteen. TurnbuU reports a case of this disease in a boy of twelve ; || it is, however, rare before the twenty-fifth year, and in young subjects generally runs a more rapid course than in older ones. * Psychiatrisches Centralblatt, Oct. 12, 1876. f " Irrenfreund," 1876. X Allgemeine Zeitschrift fuer PsychiaUie, xxxi. § There is now (1882) a "show patient," frequently brought out before visitors and reporters at the Ward's Island Asylum, if a report in a daily paper is to be credited, who had been ascertained by the writer to have for three years prior to 1877 manifested the characteristic signs of paretic dementia, and who had an epileptiform attack in that year. \ Journal of Mental Science, 1882. The father of this patient died of paretic dementia afte7- his son. A Continental alienist, the reference to whose paper the writer has lost, reports the case of an imbecile infant whose mental deficiency was complicated by a paretic trouble. PARETIC DEMENTIA. 2X7 Paretic dementia is much less frequent among females- than among males; the writer has seen but one female paretic among fifty-eight instances of this disorder in private and dispensary practice.* In various European countries the proportion of female to male paretic dements is found to fluctuate considerably. Schuele gives the highest figure, finding four paretic females to ten paretic males. Most observers give the proportion as being between i : 5, and I : 8. Neumann, an experienced Prussian alienist, did not see a single case of paretic dementia in females, and hence was led to deny its existence in that sex. The ob- servations of no single alienist can, however, be taken as gauges of the true relation of the sexes to this disease. The unusual experience of the writer, who found but one female paretic in fifty-eight cases,f chiefly observed in private practice, is probably due to the fact, that females among the wealthier classes are not exposed to the emo- tional strain and worry to which females in the lower walks of life are exposed. With this it is in accord that paretic dementia is more frequent among females who enter into' competition with the male sex, and among prostitutes who- like males are given to alcoholic excesses and exposed to syphilis. According to an old report of the Prussian statis- tical office, there were in the year 1878 20 female and 106 male paretic dements in private asylums in France, while at the same time there were 454 female and 826 male pare- tic dements in the public institutions of the same country. The proportion of females to males in the wealthier classes was, therefore, as 18 : 100; in the poorer classes, as 54 : 100, in the latter instance exceeding even the figures of Schuele. Paretic dementia in females runs a more even, less ex- plosive, and slower course than in males. The maniacal attacks in the former are not as expansive, the delusions of grandeur not as pronounced, and neither the episodical exacerbations nor the remissions are as abrupt as in the male patients. It is the persistent physical signs and the progressing dementia that chiefly serve to characterize the disease in females, as these are the same signs which in the "quiet" male cases suffice to demonstrate its existence, * The 284 remaining cases are excluded, because they were observed in an asylum for males, and the corresponding statistics of the asylum for females were unreliable. f And a single case during a visit to the Bloomingdale Asylum, where there were nineteen cases of the disease among males at the time. 2l8 INSANITY. even when delusions, hallucinations, morbid projects, and other perversions are absent. It is dementia, motor paraly- sis, and incoordination of the character described that are the necessary clinical expressions of the progressive brain wasting resulting from the morbid processes to be con- sidered in the following chapter. CHAPTER XIII. The Morbid Anatomy and Nature of Paretic Dementia. The organs of those dying with paretic dementia ex- amined by pathologists are usually obtained from subjects who have reached the last stages of that affection. The brain and spinal cord, in such cases, show the results of a long-continued and often intense degenerative process, which not a few authorities have regarded as of an inflam- matory character; and, in the sense in which the term "inflammation" is applied to the chronic interstitial changes dependent on an altered blood-supply in other organs, such as the liver and kidneys, the analogous changes in the paretic dement's brain may properly be considered to be the results of a similar inflammatory proc- ess of a low grade. The brain itself is found to be wasted; the wasting, however, is not generally even as in simple dementia, being usually more marked in some and less marked in other districts. Thus the convolutions near the base of the brain may be full, and show the normal contours, while those of the paracentral lobule, of the infra-parietal lobule, or of the entire convexity of the frontal lobe, may be atrophied, and separated by widely gaping sulci. Usually the basilar parts show no gross wasting; in two out of fifteen subjects examined by the writer there was marked reduction in the depth (dorso-ventral diameter) of the pons, which on a closer examination was found to be due to the wasting of the transverse fasciculi of that segment; in a third case there was a general diminution in all dimensions of the medulla oblongata as well as of other portions of the isthmus. This exceptional observation is of but little value, however, as the patient was over seventy THE MORBID ANATOMY OF PARETIC DEMENTIA. 219 years of age. At this period of life wasting of the axial parts of the nervous system is not uncommon. The characteristic feature of the structural cortical changes in paretic dementia is (in harmony with the gross appearances) the fact that they are rarely general, but that they affect certain cortical provinces more than others, and leave some of them nearly or entirely intact. Usually the cortex is discolored, sometimes being preternaturally pale, at others presenting a marked rosy tint, due to an injec- tion of the minute blood-vessels. In one case a rusty color was noted in several spots of the deep cortical layers, ex- tending deeply into the white substance, in large and occasionally confluent patches. The consistency varies in two ways: in some cases the cortex is less firm than nor- mal — without, however, reaching the degree of a necrotic softening, as some have claimed, — in others it is firmer than normal, and in a few the induration approaches the degree of sclerosis. Occasionally these different conditions are associated in the same case, different parts of the brain being differently affected. The writer has found that com- monly the white substance immediately subjacent to the cortex is firmer than the cortex itself, having frequently a faint bluish or grayish tinge. As the pia is more intimately adherent to the cerebral surface than in health the result is, that in some examinations, on removing the membranes, the entire cortex follows the latter, separating at the point where the softest gray tissues adjoin the firmest white layer, and thus leaving the white substance behind in a shape repeating all the anfractuosities of the surface.* A very frequent appearance, in advanced paretic demen- tia, is cystic degeneration of the cortex. The gray and some- times both the gray and white substances of some one or other area are found to be the seat of numerous cav- ities, varying in size from a pin's point to a millet seed. When these are very closely crowded the so-called gruytre cheese appearance, described by Lockhart Clarke, results. (Fig. 2f.) In several cases the writer has found these * Baillarger (Note sur une Alteration du Cerveau Caracterisee par la Separation de la Substance Grise et de la Substance Blanche des Cir- convolutions. Annates Mddico-Psychologiques, January, 1882) first accur- ately described this lesion. f Two convolutions from the mesal face of the right cerebral hemi- sphere of an aged paretic dement. The cavities in this case opened on 220 INSANITY. cavities to be branched ; in one the sclerotic stem of an obliterated blood-vessel protruded into it; and from these and a number of other observations there can be no doubt that the larger cavities at least are of perivascular origin, and the result of a retardation of the lymph out-flow, with a consequent dilatation of the spaces of His and Robin. It is possible that the smaller cavities are the result of an analogous expansion of the periganglionic (pericellular) spaces. The view that all these gaps are analogous in their origin to retention cysts, is supported by the fact that sclerosis, thickening, infiltration, and adhesion of the pia, all factors which are apt to prove obstructive to the iymph out-flow, if not to the venous return circulation, are Fig. 2. Fig. 3,f found most marked over those areas exhibiting cystic degeneration. Probably the dilatations of the lymph space in the posterior fissure of the spinal cord (Fig. 7), found in one case by the writer, are susceptible of a similar inter- pretation. The ventricles may be enlarged in advanced cases; often they exhibit no change in dimensions, and a more charac- teristic pathological feature of the disease is the granular change of their endyma or lining membrane.* This con- the surface, which is rare; h, the cortical surface; c w, cross section; c being the cortical, and iu the medullary portion of the section. * Wilder suggests this term as preferable to ependyma, which latter term may be restricted to the barren layer of the cortex to which Roki- tansky applied it. f Dorsal view of medulla oblongata: 0, striae acustici; c, coarse granulations near the apex and over the alae cin/rese (nuclei of the 6/ glossopharyngeal and pneumogastric nerves); a, finer granulations ap- proaching those producing the ground/glass appearance. -7 THE MORBID ANATOMY OF PARETIC DEMENTIA. 221 sists in a connective tissue growth of the ventricular lining, which takes place in numerous and closely-crowded areas, raising the latter in little hillocks. As long as these re- main minute they manifest their presence to the naked eye by the dulness of the normally smooth and polished lining of the ventricle; in other words, by a ground-glass ap- pearance. When they increase they assume the shape of warty excrescences, and these are found particularly well marked in the posterior half of the fourth ventricle (Fig. 3), at the foramen of Monro and over the striae cornese. Quite odd forms are sometimes seen among these bodies. Of the larger ones, which usually have a constricted pedicle (Fig. 5), two occasionally join leaving a tunnel between them. In one case the writer found the aqueduct of Sylvius divided into two channels by a series of them. The ganglionic bodies of the cortex generally exhibit marked degeneration. But, side by side with areas in which it is difficult to find a single healthy ganglionic ele- ment of fair dimensions, there may be found regions in which no change, or but very slight changes, can be found; and in one recent case the writer was unable to find any pathological condition in these elements, although sections from every district of the cerebral surface were carefully ex- amined. Mendel found that the changes in the ganglionic bodies are not always evenly developed with the ordinary signs of that interstitial encephalitis, which is ordinarily supposed to characterize the affection. In three cases in which he failed to find any indications of this process he found the peri-ganglionic spaces filled with yellowish fliocculi, the nuclei of the ganglionic bodies being indistinct or invisible, with other indications of necrobiosis.* The writer has found the following varieties of degeneration in the cortical elements: ist. An even shrinking of the pyra- midal bodies, without protoplasmic deterioration; the pro- toplasm is merely condensed, and the bodies stain more deeply than normal ones, while their processes are fragile. 2d. A diffuse yellowish discoloration of the entire gangli- onic body, extending into its processes, with a disappear- ance of the finely granular structure of the protoplasm; the body appears hyaline, does not take carmine staining, and its processes cannot be traced any considerable distance, * Report of the meeting of the Berlin Medical Society of February 14th, 1883. Deutsche Medizinal-Zeitung, iv. 8. 222 INSANITY. the nucleus may stain faintly, or not at all, but is usually visible. 3d. A coarse pigmentary change; a part of or the entire cell is filled with coarse granules of a brownish or yellowish green, and rarely of a decidedly black color; the pyramidal cells usually maintain their contour and exhibit the origin of their processes, but the prolongations of the latter are destroyed, and the nucleus is rarely visible in ex- treme degrees of this change. 4th. A " granular wast- ing" at the periphery of the ganglionic body, leaving a part of the latter apparently intact; usually a large number of free bodies are found in the periganglionic spaces in this condition, and it seems that their presence is in some way Fig. 4.* associated with this change. 5th. A progressive deteriora- tion in the protoplasmic composition; the ganglionic body is found to have its normal outline, but does not stain at all, or very imperfectly, the nucleus is shrunken, and the nerve processes appear to have broken off sharply. This is probably a sclerotic condition. All these changes are bet- ter marked in the larger elements, with the exception of the * Section from the white substance, adjoining the gray matter of the lower frontal convolution, and showing four large and several small spider-shaped cells. At y one of these cells has contracted a union with a small capillary, and one of its processes is becoming transformed into a capillary process; at 11 two coarse axis cylinders are seen. THE MORBID ANATOMY OF PARETIC DEMENTIA. 22$ second variety, which is found mostly in pyramidal cells of the second and third layers. Beside the ganglionic bodies, which show various de- grees of the enumerated changes, patches of loose pig- ment or irregular masses of no decided histological charac- ters are found, marking the former sites of destroyed ones. Little of the positive is known about the fibres of the white substance. A striking appearance in advanced cases is the distinctness and coarseness of the axis cylinder, which often appears as if dusted over with a fine powder. The course of the fibres in the white substance is much more clearly demonstrable in the brains of paretic dements than in those of healthy persons, owing to the condition alluded to, which is probably only a preliminary step to the dis- integration of the fibre. Disease of the neuroglia is almost constant in paretic dementia. It may be of every degree and present every connecting link between a general indurating and rarefying change of slight intensity, and the process known as dis- seminated sclerosis. A common feature is the presence of cells, staining deeply in carmine and provided with numer- ous brush-like processes: the spider-shaped cells of Meynert and Lubimoff. (Fig. 4.) These bodies are often found in large numbers, and the writer has never failed to discover them in advanced cases. In the shape and size in which they are found in paretic dementia they can be confounded with no normal structure, as some writers have suspected to be the case. The basis substance of the neuroglia ex- hibits the degenerative changes enumerated on page 105, and in addition considerable nuclear prolifieration. The most intense, certainly the most constant, changes of the neuroglia are found in the pons and medulla oblon- gata. Even in cases where the spinal cord is not involved, and where the cortex exhibits only a diffuse change of the kind just described, changes in color, consistency, and tex- ture are found in these parts. Sections taken from them generally stain diffusely in carmine ; a coarse molecular material scattered between the fibres, along the septa, and the raphe is found to absorb the staining fluid in a higher degree than the ganglionic elements,* and in advanced cases this material becomes the seat of a truesclerotic fibrous transformation. (Fig. 5.) * In properly hardened preparations these should always stain earliest and most intensely. 224 INSANITY. Special attention has been given by observers to the changes of the blood-vessels. Nearly everything said w^ith regard to the changes of the vascular channels on page to6 applies to their condition in paretic dementia. In the earliest stages nuclear proliferation of the walls is observed; this Fig. 5.* is particularly noticeable in the muscular coat of the arteri- oles and in the adventitia of the smaller vessels. In the former case the proliferated cells can be readily distin- guished from the normal nuclei of the muscular tunic by the roundish or irregular shape and irregular disposition of * Fig. 5. Transverse section of the oblongata, at the level of the tenth pair. G, endymal granulations of the gray and white fioor (the alae albae have lost their white color, through the connective tissue hypertrophy); R, sclerotic patch in the raphe; H, same around the roots of the twelfth pair; J', same at the ascending root of the fifth pair where crossed by the tenth; B, same around vascular gap; F, " ponticulus." The left pyramid is darker than the right. THE MORBID AXATOMY OF PARETIC DEMENTIA. 22$ the former. In addition, the spots where there is the great- est amount of nuclear proliferation (usually at the bifurca- tions of, or sudden bends in, the vessels) are also marked by the presence of granular haematoidin and other products of the retrogressive metamorphosis of blood pigment. Formed elements of the blood, both red and white corpus- cles, are always found in the adventitial space and beyond it, usually in very large numbers; a very characteristic pic- ture of the microscopic sections of the cortex in paretic dementia is the presence of a series of " nuclear" bodies along the borders of the perivascular space, many of which appear to be undergoing a transformation into spider- shaped cells (Fig. 4). With this there is apt to be found an accumulation of similar bodies in the periganglionic spaces. An amorphous yellowish substance is sometimes noted in the adventitial space, and appears to be taken up by the neuroglia nuclei in some instances.* As a rule the latter lie in clear roundish spaces, which may contain a little coarsely-granular material. In later stages of the disease the nuclear proliferation increases, and the "free bodies" undergo a transformation into branched cells whose processes are connected with the adventitia on the one hand, and with the neuroglia sur- rounding the vessel on the other. When a blood-vessel in this condition is isolated from the cerebral substance it presents a villous appearance, due to the fine processes of the branched cells attached to it. This change is most noticeable in blood-vessels of moderate dimensions, and not well marked in the capillaries. The latter are sometimes observed to establish a communication with a process of some large spider-shaped cell, which subsequently becomes hollow, thus leading to the formation of a new vascular channel. f Still later the infiltration of the adventitia and muscularis with new elements becomes less marked than the passive phenomena of degeneration. The muscular tunic becomes *This appearance has been observed not only in specimens hardened in chromic acid or its salts, but also in alcoholic and fresh preparations. It is found in other conditions. f If any analogous process occurs in the healthy state it does not occur in the same prominent manner, and certainly not as extensively as in paretic dementia. The new formation in question was first described by Lubimoff and confirmed by the writer in 1877. 226 INSANITY, granular, its nuclei decrease in number and distinctness, and the adventitia either exhibits sclerotic meshes or wast- ing. The resisting power of the vessels is evidently de- creased and fusiform dilatations are common. Sometimes extravasation of blood into the adventitial space occurs, but, on the whole, this accident is rarer than is ordinarily claimed. Very frequently the vessels are kinked and con- torted, doubled on themselves and almost thrown into coils by the excessive strain on their weakened walls (page 107); Fig. 6.* and while Sankey, who first called special attention to this condition, undoubtedly employed methods which might have led to similar and therefore false appearances in the healthy brain, and erroneously believed the adventitial sheath to be a morbid product, yet his observations as to vascular kinking are fully sustained by hardened prepara- tions. The writer has found the lumen of one vessel and ectasies of that vessel almost approaching in degree aneur- ismal dilatations divided five times by the knife in a single section. A most important field for study in this branch of morbid *Thrombic cylinder undergoing separation and checked at a bifurca- tion of a cortical capillary. THE MORBID ANATOMY OF PARETIC DEMENTIA. 22/ anatomy is the condition of injection of the blood-vessels. Usually these are more or less injected, but the most char- acteristic condition found is one of thrombic stasis (Fig. 6). Where a patient had died in consequence of a maniacal outbreak, an apoplectiform or epileptiform attack, or shortly after any of these episodes of paretic dementia (thirteen out of fifteen of the cases examined), the writer always found a high degree of engorgement in the cerebral capillaries, which in places reached the degree of a stasis more intense than any observed by the general pathologist. The blood- corpuscles in this state are so closely crowded that their outlines are no longer distinguishable, and the}' appear fused into a hyaline and opalescent cylinder which stains deeply in carmine and haematoxylin.^' When resolution takes place — a condition which is frequently observable — this cylinder breaks up into spherical and oval fragments, which are carried onward in the vascular current, becoming further subdivided at each bifurcation, and finally are represented by a number of fine granules having each the same optical appearance as the larger masses. f Thrombic stasis appears to be most persistent in the white substance subjacent to the cortex and the deepest layers of the latter. Much discussion has grown out of the claim that there is a new formation of spaces around the cerebral blood-vessels. It will be recollected that His claimed the existence of an extravascular space separating the blood-vessel from the surrounding parenchyma. In health such a space certainly does not exist, in paretic dementia it is undoubtedlj' found; we must therefore look upon it as a morbid product: the result of the distension of the true adventitial lymph space, which, subsequently retracting or wasting, leaves spaces behind. These are the beginnings of the cortical and medullary cysts previously referred to. Before leaving the brain proper and passing to the con- sideration of its appendages, it may be stated, that the most *This appearance has been correctly interpreted by Meynert and Lubimoff. Earlier observers have described a similar appearance as exudations, fatty emboli, etc. f Should it be shown that any of these thrombi on resolution pass the cortical vessels — which, owing to the tenuity of the latter (they being the narrowest in the body), is not likely — it might be possible to trace some of the multilocular pulmonary lesions observed after the apoplectiform attacks to emboli of the pulmonary vessels. At present it is safer to attribute these lesions to trophic influences, although in some cases they have been shown to be due to the inhalation of foreign bodies. ^ 228 INSANITY. intense changes are — in a crude way — symmetrical. While the left cerebral hemisphere is usually most involved, yet the difference between the two hemispheres in respect to the anatomical changes is not striking. There is scarcely a ganglion or fibre tract that may not be affected in paretic dementia, just as there is scarcely a symptom studied by neurologists which may not have been observed during the life of the sufferer from this affection. The skull may be thickened or the seat of exostoses, as in other forms of insanity. In rare instances it may be thinned and softened in consequence of a trophic change. But a more characteristic condition is an intense injection of the cranial diploe, the vessels of whose Haversian canals are filled to repletion in those patients who reach the autopsy room early in their disease. With the nutrition of the skull that of the dura is also affected. As a rule the periosteal or outer layer of this membran^e is much more adherent to the cranium than in health. In one case within the author's- experience the adhesion of the dura at the convexity was so firm that a novice pathologist neglecting to divide the dura with the bone (as should be done in all cases where an unusual degree of adhesion is found) pulled the entire and intact brain out of the cranial cavity, by tugging at the calvarium ; the sac of the dura came away almost entire- ly, tearing off at various points at the base. Such and re- lated changes in the dura are indications of an over-nutrition, as is particularly well shown in the production of genuine bony plates. Such plates are usually found in the great falx, and sometimes in the tentorium.* They are more fre- quently found in paretic dementia than in other forms of insanity, with the exception of the traumatic varieties. A typical specimen of the kind in the author's possession is about an inch long, half an inch high, and a third of an inch thick; it shows a median slit, into which the falx enters, so that it really consists of two halves, each having developed on one side of the falx, and the two communicat- ing through a hiatus in the membrane. These bodies have the appearance and structure of true bone. They cannot be confounded with the calcareous plates sometimes noted in the arachnoid. These are of a creamy white color- * They must not be confounded with the small spiculae of bone which are normally found, particularly in negroes, in the neighborhood of its- basilar insertion. THE MORBID ANATOMY OF PARETIC DEMENTIA. 229- and translucent, in no connection with the dura, with an irregular thin margin, and gaps, and are probably the re- sult of the calcareous transformation of lymph exudations. The writer has never found them to have the true bony structure of the osseous plates found on the dura, although some authors claim that bone corpuscles occur in them. A most important feature of a number of cases of paretic dementia is so-called haemorrhagic pachymeningitis. It was found in three out of fifteen cases of paretic dementia ex- amined post mortem by the writer, and in one case com- bined with a corresponding condition of the spinal dura. Baillarger observed this lesion in one eighth, and Mendel in nearly a third of his cases. In two of the three cases recorded by the writer an extensive meningeal haemorrhage accompanied this lesion, and in one of them the patient, whose spinal dura showed intense pachymeningitis, this haemorrhage extended from the olfactory lobes down to the lumbar enlargement of the cord. In the earliest stages of haemorrhagic pachymeningitis the inner layer of the dura is said to exhibit a rosy tinge, due to a vascular hyperaemia. This, according to Virchow and Kremiansky, is followed by an exudation of formed elements of the blood which, in their union on the inner face of the membrane, constitute a delicate neomembrane. It is a question whether the exudation is a genuine dia- pedesis or a haemorrhage, but the writer's observations support the probability of the latter occurrence. He be- lieves that, in a considerable number of cases, a haemor- rhage, not from the dura but from the leptomeninges, is the primary lesion; that the greater portion of the exuded blood is resorbed, but that the portion nearest the dura becomes organized and attached to it in the manner de- scribed by Huguenin. The leucocytes become transformed into spider-shaped connective tissue cells, whose processes uniting form the ground net-work for a new connective tissue in which blood-vessels with very fragile walls are developed. These grow from the dura and extend into the new formation, and their development indicates a second- ary irritation of the dura proper. A renewed hyperaemia may lead to the rupture of these feeble vessels, and a second haemorrhage then occurs between the neomembrane and the dura, or between the different layers of the neo- membrane. The same histological metamorphosis then takes place in the new clot, and haemorrhage after haemor- 230 INSANITY. rhage may recur until the enormous blood cysts known as hcRinatomata * of the dura mater are formed. A strong support for the view of Huguenin, that the haemorrhage is the primary factor, is derived from the fol- lowing considerations: It is well known that haematomata and other signs of pachymeninigitis interna are not onl}- found with paretic dementia and traumatism, but also with alcoholism, apathetic and senile dementia, epilepsy, and phthisis. In several of these disorders positive signs of lesion of the dura proper are absent; indeed, in that stage of the neomembranous formation, when it represents a sort of rust-colored lining of the dura, the inner epithelium of the latter membrane may be found intact; while there is at first, as Huguenin has shown, no tissue connection between the two. Then again, large haematomata are found as sequelae of brain atrophy, and in that event we may be sur- prised to find enormous blood cysts, whose existence no symptom observed during the life of the patient could have induced us to suspect. It would be remarkable — if the haematoma were always the result of an inflammatory proc- ess of the dura — that pain, ordinarily so prominent a symptom when that membrane is affected, should be entirely absent in some cases. Mendel thinks it inconsist- ent that if, as Huguenin claims, the neomembrane were a metamorphosis from a haemorrhage, no traces of blood pig- ment should be discoverable in some cases. Against this objection the writer has a remarkable observation to ad- vance. In a case of katatonia, on the verge of terminal deterioration and complicated by a pulmonary affection, which proved fatal, a gelatinous material was found in the meshes of the arachnoid which had a very pale rusty tinge, but was quite transparent, and at some places attached loosely to the dura as a thin film. Microscopically this material was found to be almost entirely composed of red blood corpuscles — at least, bodies resembling in every way red blood corpuscles deprived of their color, after exposure to the action of aqueous solutions. A very few black pigment granules, some streaks of fibrin, and a large number of white corpuscles were the only other elements discoverable. It required no extravagant specu- lation to imagine that the material in the meshes of the arachnoid was destined to undergo a liquefaction and ab- * Durhaematomata. THE MORBID ANATOMY OF PARETIC DEMENTIA. 23 1 sorption, while that near the dura was preparing to con- tract a permanent union with that membrane, in which event it would, had the patient lived longer and the mem- brane had time to become organized, have presented itself as one of those rusty-colored pseudo-membranous patches of the dura, in which the pathologist finds but few if any indications of pigment. Another objection of Mendel al- most answers itself. That writer finds it difficult to under- stand how, if Huguenin's theory is true, a fresh haemorrhage could be included in a haematoma, and entirely separated from the dura by newly-formed tissue. On referring to- his excellent plate illustrating the lesion in question, the inner durai epithelium is found to be nearly intact, and the transition between the "fresh haemorrhage" and the periph- eral parts of the neomembrane as delineated is so grad- ual that it is a matter of doubt whether the two were not coeval in origin. At any rate, the statement of Huguenin, that newly-formed and fragile blood-vessels penetrate from the dura into the neoplasm, covers the possible occurrence of an early haemorrhage. The changes of the arachnoid and pia may be considered together. A chronic form of leptomeningitis (inflammation involving both these membranes), with connective tissue new formation, and milky opacity, rather than purulent infiltra- tion as a result, is one of the more common gross findings in paretic dementia. The laminae of the arachnoid bridging the convolutions are with this unusually firm, and the pia is found abnormally adherent to the cortex, sometimes over the entire surface, but usually only in insulated places, particularly at the apices of the convolutions. The oppo- site condition, an abnormal looseness of the pia, is some- times found, and authors have described cases where this membrane was raised in blebs from the surface by fluid accumulations. This separation is probably due to the formation of a pathological sub-pial space, bearing the same relation to the true lymph meshes of the brain en- velopes that the pathological perivascular space of His bears to the true adventitial space. Among the organs outside of the cranial cavity which are found diseased in paretic dementia, the spinal cord de- serves the first place, for its morbid processes are often anatomically continuous with those of the encephalon. Thus arachnoid haemorrhage, changes in the dura, and in- flammation of the surface are found involving the envelopes 232 INSANITY. of the brain and cord simultaneously; while sclerotic changes are sometimes traceable from one to the other. Again, there are cases where clinical observation demon- strates that the coarser anatomical changes must have begun in the cord, and involved the brain secondarily. While sclerosis of the posterior columns of the cord, in the distribution which is typical of locomotor ataxia, is sometimes found in paretic dements, a less fascicular and symmetrical form of sclerosis is more common. Sometimes Fig. 7.* it is peripheral and the result of a meningo-myelitis, more commonly it is distributed as shown in the figure, and seems to originate in a sclerosis of the blood-vessels, and a subsequent development of a formless connective tissue, with an occasional Deiter's or spider-shaped cell. To the * Transverse section of the spinal cord from an advanced paretic de- ment. /', sclerotic patch in the posterior column apparently concen- trated around a sclerotic blood-vessel; c, collateral sulci, with sclerotic patches in their depths:/, posterior fissure, with abnormal ectasies (lym- phatic) at J, s; V, \ ascular spaces (normal) of gray substance. THE MORBID ANATOMY OF PARETIC DEMENTIA. 233 naked eye the gray matter of such a cord appears normal, while a reddish-gray discoloration of the region bordering the collateral sulci and the deeper portions of the posterior columns indicates their diseased condition. The discolored patches are firm. Under the microscope it is found that slight changes similar to those in the posterior columns exist in the lateral columns, particularly near the reticular processes. An exquisite example of the vesicular degenera- tion described by Leyden was found in two cases by the writer, who believes the vesicular spaces to be tubular in character, and to contain fluid or semi-fluid contents of Fig. 8.* the nature of myelin or some product of the degeneration of myelin. Often they contain one or more axis cylinders, and a glance at the specimen suggests the probability of these tubular spaces being the product of the fusion of several hypertrophying myelin tubes, accompanied by ob- literation of the neurilemma, and subsequent degeneration of the axis cylinders. Granular cells are sometimes found * Section magnified 500 diameters from one of the sclerotic patches of Fig. 7. Two sclerotic vessels are cleary recognizable, their lumina being nearly obliterated. The neurilemma is hypertrophied (rendered too coarsely granular in the cut), and large nuclei are found scattered in the formless connective tissue which constitutes this hypertrophy. 234 INSANITY. in and between these spaces; these bodies seem to be leu- cocytes, which have taken up the products of myelin disin- tegration. A strict line of division is to be drawn between these bodies and the so-called "granule cells" of several authors, which can be conclusively shown to be not cells, but fragments of disintegrated nerve tubules, whose car- mine-absorbing centre (so-called nucleus) is an axis cylinder fragment, and whose supposed protoplasm is the granularly degenerating myelin. Frommann's cells are sometimes observed in large numbers in the sclerotic areas. In one case — that of a negro paretic with cerebro-spinal pachymeningitis — the writer found a fascicular softening in- volving the left lateral column, and only a millimetre and a half in diameter, though it extended for the entire length of the dorsal and cervical cord. Associated with this there were wedge-shaped sclerotic patches from the level of the first to that of the eighth dorsal nerve exits. The w'hole area of the transverse section of the cord was of a dirty yellowish tint.* The ganglionic groups of the anterior horn frequently show marked changes in advanced paretic dementia, of a kind similar to that found in locomotor ataxia of long stand- ing. In such cases the coexistence of trophic disturbances has been noted by Kiernan. The nerve bodies appear to be sclerotic, their processes break off easily, and their pro- toplasm contains immense accumulations of a yellow or brown coarsely-granular material, the precise chemical nature of which it is difficult to determine. In some bodies no nucleus can be seen, it being destroyed or obscured by this morbid deposit which, as shown in the accompanying cut (Fig. 9), may almost fill the protoplasmic area. At the same time the bodies are fewer in number than in the normal cord, and residua of destroyed ganglionic bodies are found, though much less frequently than in the cortex. In one case the writer found the nerve bodies of the anterior horn, yellow in color, not taking up carmine, and with few or no traces of a nucleus — a condition which, as stated, is also found in the cortex of the hemispheres. The nerve roots may show all the changes found in pos- terior sclerosis in those cases where the spinal lesion is marked. In the majority of cases they exhibit no apprecia- * A similar discoloration was noted in nearly all the medullary districts of the brain of the same patient. THE MORBID ANATOMY OF PARETIC DEMENTIA. 235 ble diminution in size, nor any change in color or con- sistency. Much interest has been awakened by the claim of Poin- care and Bonnet, that the sympathetic ganglia show the most constant lesions in this disease. While these ob- servers based too sweeping a generalization on their find- ings, it is worthy of note that in one case, where there were pronounced trophic disturbances, the writer found a larger number of cells than usual with double nuclei, thickening Fig. 9.* of the cell capsules, and multiplication of the free nuclei between them in the interspinal ganglia, as well as pig- mentary degeneration of the inferior and superior cervical ganglia. The optic papilla is most constantly affected in that form of paretic dementia which complicates locomotor ataxia. In one case of this kind, noteworthy for the youth of the patient who was only twenty-three, the writer found white * Changes in the large nerve bodies of the anterior horn of the same cord represented in Fig. 7. In the upper part there is an apparently healthy body; the long ganglionic body shows the nucleus and granular clump side by side; in the lowermost one, the clump occupies nearly the whole protoplasmic area. 236 INSANITY. atrophy of both papillae. In an old-standing case, clini- cally a typical paretic dementia, but with which a luetic nature was probable, there was sclerosis of the temporal side of the papillae, and a corresponding defect of vision on the right side, while the left eye appeared healthy. A third case of this disease, in which there were photopsia and extensive hallucinations of fiery visions (page 202), showed marked hyperaemia of both papillae. These were the only cases of pronounced retinal disease or disturbance observed in eighteen asylum patients examined. In thirty- nine cases in private practice in which ophthalmoscopic ex- aminations could be made, there was found optic nerve atrophy in three cases, choked disk in one, and a pronounced hyperaemia in four; the single female case had the most pronounced atrophy found in this disease by the writer. Such assertions as those of Clifford Albutt, who claimed that the papilla was atrophied in forty-one out of fifty- three, less severely affected in seven, and healthy in only five cases, are, to say the least, startling. The changes of other organs and structures, such as those of the lungs, heart, stomach, and bowels, the bones and skin, inasmuch as they are, as far as an intrinsic rela- tion to paretic dementia is concerned, secondary to the cerebral disorder, and have a similar pathology and etiol- ogy as the same changes, studfed by the general neurologist, require no detailed consideration here. THE RELATION BETWEEN THE LESIONS OF THE NERVOUS SYSTEM AND THE SYMPTOMS OF PARETIC DEMENTIA. As previously indicated the majority of those patholo- gists engaged in the study of morbid changes which are most frequently found in paretic dementia have, through the frequent discovery of material and destructive lesions of the cerebral cortex, been led to consider this disease as an essentially inflammatory, or at least as a degenerative, process. While this is true with regard to the terminal and active phases of the disorder, it is a question whether the condition of the brain in the earlier periods of paretic dementia justifies us in assuming an inflammatory or de- generative change to exist from the beginning. If the intrinsic factor of the morbid process underlying this disease were an inflammation, or a primary progressive histological deterioration, the evidences of these conditions, THE MORBID ANATOMY OF PARETIC DEMENTIA. 237 which are readily discovered and unmistakable, would be found in the brain of every paretic who reaches the au- topsy table. This, however, is not the case. Well-authen- ticated instances are on record where no marked lesion was discoverable, and one of the most reliable investigators* in this field takes special occasion to mention this fact. In the writer's experience, one case has occurred in which nothing was found beyond the ordinary appearances pre- sented by the brains of sane persons, excluding the stasis- like condition above described, and which can be interpre- ted neither as a degenerative nor as a strictly inflamma- tory process in the ordinary acceptation of the term. Then again, if a degenerative or inflammatory process, or, in short, any profound tissue change were the funda- mental lesion of this interesting disease, it should, in its ex- tensity and intensity, stand in a rather constant relation to the amount and character of the mental disturbance. This has been found to be so in all cases which had run a long course; but, in several others which had terminated within two years from the date of the first manifestations, the writer failed to find any harmony between the extent and severity of the tissue lesions and the symptoms. It was the consideration of this fact that led Poincare and Bonnet to search in the sympathetic ganglionic sys- tem for those disturbances which the brain refused to reveal. That they mistook appearances occasionally oc- curring in health for disease, and secondary processes for primary lesions, does not detract from the value of the principle they were endeavoring to establish, though their observations as observations cannot be utilized to support it. As we have seen, changes in the sympathetic ganglia are sometimes found, but they are much less pronounced than those of the central nervous system. It is more than probable that the vaso-motor system con- trolling the cerebral circulation is, at least in part, in the brain itself, and that its initial disturbances are as little tangible to the microscope as they are with other disturb- ances of the same system — for example, in epilepsy. The most furibund of the symptoms ever manifested by paretics are: First, high maniacal explosions, with great destructive tendencies, and often with rapid flight of ideas; second, apoplectiform attacks; third, epileptiform attacks. *Theo. Simon. " Die Gehirnerweichung der Irren." Hamburg, 1871. 238 INSANITY. The first of these symptoms, which is not at all as con- stant as is generally supposed, is found in its most perfect development in early periods of the disease. It appears as if the profound lesions ensuing in the later stages of the affection were inimical to its full development. The sec- ond is found variably, more frequently and fatally in the last stages. The third is also found variably and more frequently in the last stages of the disease, but exception- ally convulsions are the very first evidences of the latter. Each maniacal, apoplectic, or epileptiform exacerbation leaves the patient permanently more crippled than before, either in his motor or psychical field; rarely, however, the contrary, a relatively complete restitutio ad integrum, takes place. A patho-physiological theory of the disease must take into account and harmonize all these facts. It must offer an explanation for the facts that the maniacal explosions are less perfect in the last than in earlier stages of the disease; that tlie most violent symptoms may occasionally open the clinical picture; that, as a rule, each exacerbation leaves the patient worse, though a remission and temporary improvement are not out of the question. The supposition of a strictly inflammatory process is in- compatible with the occasional appearance, as the first evi- dences of the disease, of epileptiform spasms which are not followed by those immediate sequelae ordinarily following such an inflammation. It is incompatible with the very rapid and relatively complete remission of the symptoms. It is also known that certain of the injurious physical influen- ces provoking the disease, such as violence directly or indi- rectly affecting the cranium, and insolation as well as other forms of overheating, do not always act on the brain through the channel of a meningitis or other inflammatory process.* All these facts can be harmonized by assuming the essen- tial and primitive anomaly in the paretic's brain to be a vaso-motor disturbance. This assumption is in strict ac- cordance with the observations made on the brain after death. In every case where the patient died in a maniacal attack, * In Arndt's cases (soldiers dying from overheating after a forced march) the majority showed a pale brain, without visible morbid ap- pearances. THE MORBID ANATOMY OF PARETIC DEMENTIA, 239 or shortly after such a one, or in an epileptiform state, or with apoplectiform symptoms, the writer constantly found the capillary thrombi, which with Lubimoff he considers to be the expression of a blood stasis. That stasis is to be re- garded as the result of a paralysis of the muscular coat of the blood-vessels, over-distended by the efferent blood col- umn, in its turn an indication of hyperaemia. A cortical hyperaemia would explain the expansive idea- tion, and the motor excitation; the arrest of the blood cur- rent through stasis, the subsequent congestive and coma- tose states. A sudden stasis, causing sudden arrest of the cortical functions, would satisfactorily account for the epi- leptic manifestations. A cortical hyperaemia, as a factor that may, on the one hand, vanish with the most violent storm sweeping over the mental plain, without leaving a permanent defect; and, on the other hand, in its repeated recurrence, determine those structural changes which account for the permanent symptoms of the disease, would also, in its necessarily progressive severity, account for the progressive greater gravity of each exacerbation, and the final preponderance of symptoms of subtraction such as paralysis, lacunae in the memory, aphasia and coma, over those of functional excitation, such as the destructive ten- dencies, constructive scliemes, ambitious delusions, and flight of ideas of the earlier periods. As the disease progresses, and the resisting tone of the vessels decreases more and more, stases are found to occur not only in the exacerbations of the disease, but also in the intervals; here more restricted in extent and less pro- nounced, so that with proper methods of preparing histo- logical specimens the writer believes that no lesion will be found so constantly in the terminal periods of the disease as the capillary thrombi resulting from such stases. Of course, with this explanation we are as much in the dark as ever as to the organic basis of the vaso-motor diffi- culty. As above stated, this consists in a probably impal- pable morbid state of the encephalic vaso-motor centre. Such a morbid state it requires no stretch of theory to consider inducible b}' mental overstrain, by the repeated hyperaemias of alcoholism, rheumatism, and certain forms of syphilis, or by typhus fever, insolation, and the molecular disturbances determined by concussion, directly or indirectly involving the skull contents. While the essential factor in the development of paralytic dementia would, in this light, 240 INSANITY. be constituted by the vaso-motor difficulty, a direct influ- ence of many of the causes supposed and known to provoke disease of the cerebral tissues need not be excluded. In fact, for some of the syphilitic forms and those cases in which the writer believes a multiple sclerosis to be the essential lesion this seems to be the case, and we may some day have to draw a line between those cases with which the vaso-motor anomalies are in the foreground, and those with which they are in the background. A careful study of certain cases of cerebro-spinal sclerosis, constituting connecting links between the t\^pical disease and "chronic" varieties of dementia, may yet show that vaso-motor derangement plays a far more important role also in that disease than is generally imagined. Apoplecti- form and congestive attacks are also encountered here, and they present many points of resemblance to those of genuine paretic dementia. When it is recollected that a large per- centage of the cases of multiple sclerosis is ascribed to concussion as a cause, by Erb and other authors, the attrib- uting of certain cases of paralytic dementia to the same cause by prominent alienists merits renewed attention, as bearing on the vaso-motor etiology of the disease. In this connec- tion it may be well to refer to some remarkable analogies of paretic dementia, with typical posterior spinal sclerosis. Both diseases are more .common in the male than in the female, and under certain circumstances occur nearly in the same proportion in the sexes. Both have been attributed to sexual excess as a cause. With regard to both the syphilitic dyscrasia plays the same role. Cranial or spinal symptoms may open the history of either, and these symp- toms show a striking analogy. Thus amblyopia and di- plopia may be the first indications of posterior sclerosis, so may color-blindness, optic nerve atrophy, and diplopia be the first signs of paretic dementia. The essential cerebral signs of paretic dementia may be complicated by the typi- cal picture of posterior sclerosis; so the latter may be com- plicated by paretic dementia. Paretic dementia is patho- logically a progressive brain-tissue deterioration, which is the basis of the progressive and constant symptoms of sub- traction found in this disease; while certain episodes — maniacal, apoplectiform, epileptiform, and trophic accidents — mark its progress, which cannot be explained by that lesion alone. Similarly, posterior sclerosis is pathologically a tissue degeneration of a considerable part of the cord. THE MORBID ANATOMY OF PARETIC DEMENTIA. 24I and certain phenomena are constant and progressive in its clinical history, and can be explained by its lesions; but there are episodes such as gastric, nephritic, and other crises which cannot be accounted for by the lesion alone; and some of these episodes, like the acute maniacal outbreaks exceptionally observed, show that they may even assume a psychical character. In short paretic dementia and pos- terior spinal sclerosis appear to be similar if not patho- logically identical processes, only differing in their location, the former being concentrated in the brain, the latter in the cord. There are a number of facts which point to the early involvement of the brain isthmus * in paretic dementia. In the first place, the morbid changes are frequently ob- served to be further advanced here than in the cerebral cortex. In the second place, not only the paralytic phe- nomena indicating an affection of the nerve nuclei and the emerging roots, but also certain emotional disturbances, point to the oblongata and pons as the seats of at least a functional disturbance. Reference is here particularly made to the fact that paretic dements exhibit emotional manifestations opposed to their true emotional state; thus, while relating a pleasant reminiscence, such a patient may burst into tears, and, while complaining of an affront or of persecutions, smile. Similar disturbances are noted in organic disease of the medulla oblongata. f This view is also supported by the fact, that at certain periods in the progress of spinal disease, when the morbid process reaches the oblongata, mental symptoms develop, which are strikingly like those of paretic dementia, and imitate both the "melancholic" and "maniacal" types of that disease. Grouping together all that is known about the interest- ing affection we are considering, and amalgamating the clinical and anatomical facts with the physiological theory, the conclusion follows, that paretic dementia is a progressive deterioration of the central nervous system, chiefly affecting the brain, and the result of a chronic inflammatory process of an angioparalytic nature, whose essential element, the vaso-motor * The medulla oblongata, pons, and peduncular region. f In a dispensary patient with complete anarthria, the tongue lying motionless at the bottom of the mouth, this was noted as a salient symp- tom of the organic disease (tumor of the medulla?) from which she suffered. 242 INSANITY. weakening, is due to overstrain of the encephalic vaso-nwtor centre, the exacerbating and retnitting course of the malady, being the clinical expression of the struggle of that centre to regain its equilibriu7n. Owing to the multiplicity of lesions found in advanced »cases of this disease, it is but rarely possible to establish a relation between localized lesions and special symptoms. As to the most essential symptoms from the alienist's standpoint, the mental disturbances, the fact that in paretic dementia there is a diffuse or multilocular disease of both cerebral hemispheres, is in such striking accord with what we know of the seat of the mind that we may assume that this disease is the basis of the progressive mental failure. A further localization of the strictly mental symptoms is im- possible, and we may content ourselves with the assump- tion that the frequently lacunar character of the amnesia is in harmony with the fact that the cortical provinces are not all equally diseased, some districts being relatively in- tact, and others destructive!)' involved. It is a significant fact that those movements which depend on the voluntary motor association of smaller muscular peripheries suffer earlier than those which depend on the combination of the coarser groups. This appears to be in parallelism with the fact that the lesions, at first of slight extent, involve the smaller cortical areas, and subcortical associating fibres more completely than the larger areas and deeper tracts,* which are seriously involved only in the later stages of the disease. It is, however, very diffi- cult to obtain much valuable material in support of the localization theory in paretic dementia. If it were onl}- the cortical gray matter that is diseased the subject would be difficult enough, but there are also found changes in the lower segments of the nerve-axis which must have an im- portant influence on the motor and sensor}- functions, and which must be taken into account. Thus the sclerotic patches in the course of the cranial nerves, the raphe, and other important tracts, the degenera- tive changes in the nerve nuclei of the oblongata and cord, as well as the disease processes in the cord, account for many of the ataxic, paretic and paraesthetic plienomena of * The fibrcE arcuatce s. propria, which unite adjoining cortical areas, run immediately underneath the cortex; those uniting more distant areas run more deeply. SYPHILITIC DEMENTIA. 243 the disease. The speech defect in paretic dementia may, as in the patient whose medulla oblongata is figured on page 224, be of the anarthric type, that is, not truly aphasia, and hence not referable to the lesion of the hemispheres. The only really valuable contribution to the study of the areas of specialized function in the cortex is that made by Fiirst- ner, who found that visual disturbances of the kind experi- mentally produced by Munk, by destruction of the occipital lobes in monkeys, are found in paretic dementia when there is pronounced lesion of the posterior part of the cerebral hemispheres. A case in point coming within the writer's observation has been referred to in the last chapter. CHAPTER XIV. Syphilitic Dementia, Syphilis is an important etiological factor in certain cases of insanity. In most of these its influence is rather of a psychical than a somatic character, as in the syphilitic hypochondriasis and self-accusatory melancholia observed by Erlenmeyer, Here the only direct influence of the dis- ease is manifested through the associated impoverishment of brain nutrition; and although anti-syphilitic treatment is most successful in combating these conditions, this does not prove that the brain state underlying them has any specifically syphilitic characters. The same remarks apply to the insanity sometimes noted with the secondary fever of syphilis, and which has not thus far been demonstrated to be associated with a palpable and constant change in the brain or its vessels. It is different with syphilitic dementia — a chronic mental disorder which, from its association with anomalies of mo- tility and speech, bears a great resemblance to paretic de- mentia and to dementia from organic brain disease. Here demonstrable brain lesions, standing in a constant relation to the symptoms, are found in the majority of cases. In some cases syphilitic pachymeningitis or leptomeningitis and gummy infiltration of the membranes preponderate; in others multilocular gummata of the brain substance, or the luetic arterial change, with its results, are the most notable 244 INSANITY. morbid anatomical features. In one case described by the writer some years ago, over a thousand perivascular no- dules, single and branched, varying in size from that of a pin's head to a pea, were found scattered through the cere- bral tissues and associated with a surface infiltration of the cortex. Tlie pre-lethal symptoms in this instance were in no way distinguishable from those of a maniacal exacer- bation in a deteriorated paretic dement. As a rule the symptoms associated with these morbid conditions are characterized by variability, and an almost pathognomonic feature is the accompaniment of the earlier mental symptoms by pronounced paralysis of single mus- cles, or of definite muscular groups supplied by one or two cranial nerves. It is an ordinary history of the inception of syphilitic dementia, that after such prodromal signs as headache and vertiginous or syncopal attacks, the patient ma\' awake with ptosis, facial paralysis, aphasia, or para- lytic weakness of a leg or an arm. These symptoms rapidly disappear, and may as rapidly recur. With this the patient exhibits lacunae* in his memor\', an undue irritability, and intolerance to alcoholic liquors. Clinically it is not always possible to make a sharp discrim- ination between syphilitic dementia and paretic dementia proper, for syphilis plays an important role in the etiology of the latter affection. Indeed, Snell claimed that seventy- five per cent of the cases of paretic dementia coming under his observation were due to syphilis, a claim which is in re- markable parallelism with that recently advanced by Erb, with regard to locomotor ataxia, in which a similar rela- tion is supposed to exist. Other authors find a smaller proportion of syphilitic paretic dements than Snell. Mendel found that of 201 patients 117 were syphilitic, and Ripping could only detect a syphilitic element in about twelve per cent. It is to be borne in mind that the mere co-existence of a syphilitic taint does not prove a given form of insanity to be syphilitic; but the fact is significant that, of «// syphi- litic lunatics, one half are paretic dements, or suffer from the allied form of disease we are here considering. In the writer's experience S}'philis is an etiological factor in the production of various forms of progressive dementia *Erlenmeyer calls attention to this as a constant feature, and cites in- stances where a special series of events were blotted from the mind, leaving other recollections intact. This is also found in paretic dementia. SYPHILITIC DEMENTIA. 245 in about one third of the cases among- the pauper insane of New York.* Its existence could be determined in fourteen per cent of the paralytic patients in private practice. Of these eighty per cent had typical paretic dementia, and the remainder the true syphilitic form of dementia. Numerous attempts have been made to establish some criterion, on the strength of which to be able to distinguish syphilitic from typical paretic dementia ; but these do not always hold good. Thus, it has been supposed that the association of true locomotor ataxia with paretic dementia, proves the syphilitic origin of the case. But there are non- syphilitic tabetics who become paretic dements, while there are syphilitic dements who are not markedly tabetic. On the other hand, observers have suggested the empirical test of an anti-syphilitic treatment, which was supposed, if successful, to demonstrate that the disorder was of syphili- tic origin. r But we know that spontaneously remissions fV occur in ordinary paretic dementia, while in unquestioned / syphilitic cerebral disease the most energetic anti- syphilitic treatment may fail. The writer has found that both mer- cury and iodide of potassium appeared to be of service in cases where a luetic infection could be positively excluded ; and Ripping goes so far as to claim that he has seen in- * It was impossible to obtain accurate information, and the estimate here given is probably under the truth. f This procedure has been very faithfully carried out by Dr. Allan McLane Hamilton, who says: " When an apparently strongman comes to us with a history of fugaceous aches and pains, inconstant spasms, and dis- ordered subjective sensations — notably among which are subjective cold — we should not immediately make light of his troubles, and even dismiss him for change of air and scene, but empirically, if our history of cause is not clear, place him upon proper anti-syphilitic remedies." ("Syph- ilitic Hypochondriasis ; Alienist and Neurologist," vol. i., No. i, page 79). Ripping (Ueber die Beziehungen den Syphilis zu den Geisteskrank- heiten mit und ohne Liihmungen, Allg. Zcitschrift fuer Psychiatrie) makes the following comment: "Such views as those I above cited from Allan McLane Hamilton, it may be safely claimed, have no uphold- ers, among German physicians at least." As to this remark it may be said, that it manifests a tone of criticism which is becoming rather too common in Germany. Science is international, and if an absurd and ridiculous view is announced by an American physician, that is no justi- fication for raising an international question. In the present case the implied inference that such views as the one criticised are shared by the American medical profession would be in the highest degree unjust; for " it may be safely claimed" that no other American writer, nay, that no other writer anywhere, has ever announced or held such a view as the one which Ripping — properly enough — finds fault with. 246 INSANITY. sanity in syphilitic subjects recovered from, although no anti-syphilitic treatment of any kind had been applied. After the prodromal period referred to, the course of syphilitic dementia is progressively, and usually very slov^dy, toward a fatal termination.* Delusions are not prominent, and rarely expansive, though, in paretic dementia from syphilis, the unsystematized delusions of grandeur may be as well marked as in non-syphilitic cases. f Sometimes the terminal period of an at first clinically well-marked syphi- litic brain disorder is in no way distinguishable from typi- cal paretic dementia. J It is possible that with the progressing accumulation of clinical and pathological material, syphilitic dementia will share the fate of "syphilitic meningitis," which is now known to differ in no essential respect from ordinary men- ingitis, except in those rarer instances where the specific gummatous character prevails. It is to cases correspond- ing to the latter that the term syphilitic dementia should be limited. * In one case of syphilitic dementia, closely approaching true paretic de- mentia, a remission occurred which lasted four years, the patient, a phy- sician, returning to his practice. The case has since been lost sight of. f Fournier erroneously claimed the contrary, and termed paretic de- mentia from syphilis " pseudo-paralysie generale." Foville showed that in syphilitic paretic dementia the delusions may be as expansive and varied as in any case, and some of the most characteristic delusions re- lated in the last chapter were observed in syphilitic patients. Then, too, it must be recollected that in non-syphilitic cases, delusions may be ab- sent ; for this reason alone Fournier's claim would be faulty. X Since the above was written a striking confirmation of this occurred in the writer's consultation practice. He was called to examine a patient who had for a year been under the treatment of one of the best clinicians in New York for syphilitic cerebral trouble. For a period of several months he improved considerable on anti-syphilitic medication. When examined by the writer, he exhibited a lachrymose hypochondriasis, with some of the motor symptoms characterizing paretic dementia. The diag- nosis of this disease was made. Two days later he had three epileptiform attacks, and subsequently to these manifested gross amnesia, hilarity, ex- travagant projects, and delusions ol physical strength. DELIRIUM GRAVE. 247 CHAPTER XV. Delirium Grave. There is a comparatively rare form of derangement, ap- proximating in many respects to maniacal delirium, and yet distinct from it in many essential features, vi^hich has been variously termed typ/iomaiiia, mania gravis, phrenitis, and acute delirimn. This disorder differs from the simple psy- choses in the fact that it depends on a stormy pathological process; and while the motor excitement and the angry fury of the patient seem to be clinically only a higher degree of maniacal furor or melancholic frenzy, there are somatic signs which justify the pathologist in comparing delirium grave to the cerebral disturbances which follow severe and exhausting febrile processes, such as pneumonia and typhus. As Schiiele has aptly said, the symptoms of a spurious maniacal furor mark the first period of the disease, while the symptoms of grave cerebral exhaustion charac- terize the second.* This disorder is more common in females than in males; this is related to the fact that the puerperal state is often found to stand in a causal relation to grave delirium. It is preceded and undoubtedly caused by profound nervous or physical exhaustion and overstrain. Schiiele has known it to result from excruciating physical suffering. In most cases it is noted that the patient has for a long period of time been in a feeble state of health, and that some extra strain on his nervous system, such as a business crisis, f an alcoholic excess, an emotional strain, J or the puerperal state, precipitates the breaking out of the delirium. The mental signs may be briefly characterized as resem- bling the highest degrees of maniacal furor and melancholic * " Handbuch der Geistes-Krankheiten," von Dr. Heinrich Schiiele (" Ziemssen's Handbuch"), vol. xvi., 1878). f In the case of a lawyer, who for many months had suffered from in- somnia, this disorder exploded after the preparation of an argument. X Abandonment of seduced and pregnant girls is a prominent element in the history of a number of cases. 248 INSANITY. frenzy.* The)' differ from these states in their mode of development. While maniacal and melancholic frenzy are preceded by the ordinary and readily recognizable symp- toms of typical mania and melancholia, the outbreak of grave delirium is either sudden or preceded by a state of impaired consciousness of a kind not found in mania or melancholia proper. Thus, some patients in this state ex- hibit a panphobia like that of febrile delirium, while others wander about aimlessly, staggering as if drunk. The ideation of grave delirium is much more incoherent than of frenzy, and is usually the expression of an angry or a frightened state. While in the beginning the patient may still articulate sentences, his speech rapidly deterior- ates, and he is finally unable to pronounce S3'llables. As far as the expressions of the patients permit us to judge, they have hallucinator}' visions of the day of judgment, of conflagrations, of bloody scenes, or of those connected with the exciting cause. Sometimes a set phrase is repeated over and over again; usualh' it has some relation to the emotional calamit}'^ provoking the outbreak of the disease. The seduced girl will count as if hearing the bells that toll out the hour of an assignation, and then suddenly break out in a piercing cry or a sill}'^ laugh. The business man, who lias become delirious after a period of business worry, re- peats figures or names of articles of trade, of firms, or of stocks, in an incoherent jumble.* Delusions of grandeur are *Schuele speaks of a melancholic form of acute delirium whose symp- toms and anatomical basis are said to be the very reverse of the maniacal form. The writer is unable to recognize in the description anything but a stupid melancholia, developing on a basis of extreme physical ex- haustion. Neither the temperature, nor the mental signs, nor the relatively better prognosis of Schiiele's melancholic form, support his view that it is due to as grave and active a pathological process as grave delirium. f The recorded cases of " meningitis from over-study" are in fact cases of grave delirium. They are brought about as much by the emotional strain attendant on competitive examinations, as by the mental effort itself. It is never a strong mind nor a healthy body that suffers in this way. ' ' The mental hygiene" sensationalists who periodically "enlighten" the pub- lic through the columns of the press, whenever an opportune moment for a crusade against our schools and colleges seems to have arrived, are evi- dently unaware of the existence of such a disease as grave delirium, and ignorant of the fact that the disorder which they attribute to excessive study is in truth due to a generally vitiated mental and physical state, perhaps inherited from a feeble ancestry. Our school system is respon- sible for a good deal of mischief, but not for meningiiis. DELIRIUM GRAVE. 249 exceptional. In one case, that of a woman without a pre- vious history, whom the writer saw through the invitation of the city physician, Dr. Hardy, there were expansive though vaguely expressed sexual ideas; she recognized every male and female visitor as one of a large number of husbands. With these deliria there is great restlessness; the pa- tients make aimless efforts to escape from those around them, or kick and strike in all directions. Sometimes rhythmical motions are observed; one patient under the writer's observation continually rolled his head from side to side day and night (as far as watched) for a period of three days. Grinding of the teeth, strabismus, contraction of the pupils, and convulsive movements mark the transi- tion to the second period of the disease. There is in many cases absolute insomnia, and while the general nutrition of the patient suffers appreciably, the temperature rises to over 100° F. and may reach 105° or 106°. The pulse becomes-frequent (130 in one case), soft, compressible, and the sphygmographic trace indicates extreme cardiac enfeeblement. The second period of the disease is analogous to the post-maniacal reaction which follows the outbreaks of sim- ple mania. There is now extreme mental and physical de- pression. The patient lies apathetic, mute, collapsed; has a staring or startled look; does not recognize what is going on around him; or, if he shows an}?- signs of mental life, these are limited to incoherent expressions and purposeless and feeble movements. If the patient does not die in this con- dition he passes into a state resembling, as Jessen remarks, the convalescence from typhus, without the favorable ter- mination of the latter. It was this feature that induced Luther Bell to designate the disease " typhomania." The severity of grave delirium is specially manifested in certain somatic sequelae of the excited period. The hair falls out, the skin desquamates and is cyanotic, the nails ex- hibit an atrophic zone corresponding to the period when the disease was at its height, the spleen is slightly enlarged, the intestinal tube relaxed, symmetrical atrophy of certain muscular groups occurs, and the reflexes, which at first were exaggerated, become diminished. In one of Jessen's patients anaesthesia became so extreme that he gnawed off the un- gual phalanx of one of his fingers. That author * claims that * " Ueber die klinische Aeusserung der Reactions-Zustiinde acuter De- lirien. Allg. Zeitschrift f. Psychiatrie. 18S0-1. 250 INSANITY. pemphigus-like vesicles appear in the otherwise apparently healthy skin, especiall}^ of the dorsal faces of the hands and feet. He believes this to be a comparatively constant sign; it was absent in tw^o out of the five cases observed by the writer, while phlegmons and spontaneous gangrene were addition- ally noticed in one of the cases that had pemphigus. Most of these conditions are due to the vaso-motor paresis which marks this period. The majority of the patients affected with grave delirium die in the delirious period after an illness of a few weeks; in those who do not die at this period the excitement con- tinues unabated for four or five weeks, the subsequent symptoms of stupor increase, and the history closes with a fatal coma. Complete recovery never occurs; in rare instances the patients emerge from this severe disorder with a slight mental defect, in others paretic and terminal dementia su- pervene. The morbid anatomy of this disease consists in an intense hyperaemia of the brain and meninges. This is constantly found in patients dying in the excited period of the disorder; in those who die in the stuporous period, the hyperaemia is sometimes obliterated by a collateral oedema; but in all the brain appears swollen, the cortical ganglionic elements are granular or opaque, stain poorly, and their perigangli- onic spaces, like the adventitial lymph sheaths, are literally crammed with the formed elements of the blood. In the single case examined pos^ mortem by the writer white streaks were found on either side of the larger vessels in the pia. Microscopic examination showed that they were due to an accumulation of leucocytes, whose preponderance suggests an inflammatory nature of the lesion rather than the condi- tion of venous engorgement claimed by Krafft-Ebing. A most positive sign of inflammation was found in the case referred to: the arterioles were surrounded by an area staining in carmine with a beautiful pink flush, probably the expression of a molecular infiltration, while layers of newly-formed fibrin were found in and around the adven- titia. That grave delirium is the result of a vaso-motor over- strain analogous to that supposed to exist in paretic demen- tia is supported by the etiology, the manner of origin, and the somatic sequelae of this disorder. CHRONIC ALCOHOLIC INSANITY. 25 1 CHAPTER XVI. Chronic Alcoholic Insanity. Alcoholic excesses play an important role in the produc- tion of insanity. Ordinarily the insanity which results from such excesses belongs to the groups already described. Thus a typical acute mania or melancholia may follow a prolonged debauch, and the influence of chronic alcoholism as a predisposing factor in the etiology of paretic dementia and delirium grave is well known. There are also certain mental disturbances of a character peculiar to alcoholism, which are not ordinarily ranked with insanity, but which have all the elements of the psychoses — such are the various states of drunkenness itself and delirimn tremens* In addi- tion there are various forms of dementia associated with motor disturbances, which depend on the organic changes produced by alcohol in the brain and its membranes, and which appertain to the group of "dementia from organic disease." While organic changes are common in the brains of sub- jects who had been addicted to alcoholic excesses, and while the dementia just referred to is with its accompany- ing motor and sensory symptoms present, in however mild a degree, in all persons suffering from advanced alcoholism, not all forms of mental disorder found in such subjects properly belong to the group of dementia or insanity " from organic disease." Just as epileptic or hysterical insanity may develop as an epiphenomenon on the epileptic or hys- terical neurosis, so a special form of alcoholic insanity may become engrafted on the alcoholic neurosis. It has distinct clinical as it has special etiological characters, and alone merits the designation of chronic alcoholic insanity. Before proceeding to characterize this psychosis it is well to survey the extensive pathological territory of inebriety of which chronic alcoholic insanity is but a province. The inebriate generally exhibits moral turpitude, indifference to his interests and his family, morbid irritability, emotional depression, to overcome which the libations which provoked it are repeated and prove temporarily remedial, and above * A detailed description of these conditions is here omitted, as they are usually treated of in extenso in works on general neurology and clini- cal medicine. 252 INSANITY. all, a marked enfeeblement of the will. This enfeeblement of the will is at first manifested in the inability of the ine- briate to resist the temptation to drink. Numerous cases are on record where prosperous business men and capable men of letters, feeling this abulia, voluntarily went to an asylum for inebriates, and within its walls carried on their labors as well as before they had formed the alcoholic habit. But, with the continuance of the vice, the volition becomes impaired with regard to other matters as well,- and the confirmed and deteriorating inebriate becomes the tool of others. He attends fairly well to duties of a routine character, but is devoid of initiative, or, if he has it, is in- consistent and easily diverted from his purposes. With this there is noted a general impairment of all the intellec- tual faculties, the memory is gravely weakened, and the reasoning powers become clogged. With these mental symptoms there are positive signs of the disorder of a somatic character. The most important and constant sign is the alcoholic tremor. This tremor has the peculiarity that it decreases under the influence of alco- holic beverages, and is most marked when the patient is perfectly sober. It is best observable in the hands, tongue, and lips. Crampi and clonic spasms sometimes occur in the extremities, and muscular anenergy is frequently com- plained of, being most pronounced in the extensors of the leg. In extreme cases an actual paraparesis, or even para- plegia (Wilks), probably independent of a structural lesion, may ensue. Hypercesthesias and anaesthesias are usually among the later symptoms of chronic alcoholism, and not unfrequently has the diagnosis of incipient paretic dementia of the as- cending or spinal type been made on the strength of an anaesthesia of the legs and feet, coupled with the lax facial innervation, enfeebled memory, hesitating speech, and tre- mor of chronic alcoholism. Occasionally, lightning-like pains and analgesia are observed, and in severe cases al- most any form of sensory disturbance may be found, from the unilateral haemi-anaethesia observed by Magnan to the amblyopia noted by Galezowski. The latter condition may even be associated with atrophy of the optic nerve.* * In the case of a gentleman whose will was made the subject of litiga- tion, and who undoubtedly during his later years suffered from alcoholic dementia, the distinguished ophthalmologist, Knapp, discovered atrophy of both optic nerves some years before marked mental impairment had set in. CHRONIC ALCOHOLIC INSANITY. 253 Most chronic alcoholic patients are anaemic and badly nourished, for there is usually more or less hepatic and renal trouble, there is always gastric or gastro-duodenal catarrh and general degeneration of the vascular system. The latter manifests itself in the well-known fatty degen- eration of the cardiac muscle, and in ectasis of the capillary and atheroma of the larger blood-vessels. The facial appearance and attitude of the chronic inebriate are characteristic. There is a general laxity of muscular tone, the body is inclined forward, the knees bent, the eyes dull, and the face generally defective in expression. Most authorities state that the pupils are dilated, but the writer's experience, however exceptional it may be, is to the con- trary. The above may be looked upon as the prominent signs of a constitutional deterioration of a neurotic character; and an analogy may be detected between the progressive mental enfeeblement of the epileptic, which is in relation to the fre- quency of the fits, and that of the inebriate, which is in re- lation to the frequency of his libations. On this chronic alcoholic constitution as a background, the well-characterized psychosis which is the subject of this chapter may develop just as epileptic insanity crops out on the surface of the epileptic constitution. It is noted that positive signs of mental derangement are found in a great many inebriates met with in general practice. Hal- lucinations, chiefly of vision, are very common with them, and are almost without exception of a frightful character; they may lead the patient to the commission of brutal crimes in subjective self-defence. In addition, many inebriates entertain, if not delusions, at least unfounded suspicions of marital infidelity. When these symptoms become constant and prominent, the psychosis first described by Marcel,* is before us. The patient, after a brief prodromal period marked by congestive attacks and headache, and under the influence of the characteristic hallucinations of alcoholism, becomes the subject of delusions of persecution, and very rarely there may be superadded expansive ones. Krafft- Ebing f happily draws the line between these delusions, which are exclusively determined by hallucinations, and * Marcel, " De la Folic Causee par I'Abus des Boissons Alcoholiques." Paris, 1847. f Op. cit., p. 1S6. 254 INSANITY. the persecutory delusions of monomania, which are some- times associated with hallucinations, and become confirmed by, but are never provoked by them. The persecutory delusions of alcoholism relate to the sexual organs, to the sexual relations, and to poisoning. This fact is so constant a one that the combination of a de- lusion of mutilation of the sexual organs with the delusion that the patient's food is poisoned, and that his wife is un- faithful to him, may be considered to as nearly demonstrate the existence of alcoholic insanity as any one group of S5^mptoms in mental pathology can prove anything. With this there are unpleasant hallucinations. The patient, who fears that he is about to be castrated, hears people com- menting on the fact that he has a loathsome venereal affec- tion, or that his penis is too small for its purposes, and smells seminal discharges which are drawn from him at night. Delirious exacerbations are likely to occur in conse- quence of the patient's morbid fear, and in brutal fury he may hack the wife, whom he suspects of infidelity, to pieces. There is this peculiar feature about the delusions of insane inebriates, that their acts are not consistently regu- lated by their delusions.* Thus one patient may live in comparative tranquillity with a wife whom he suspects of committing adultery in the boldest manner and before his face night after night. Another, under the influence of the same delusion, may, in mortal fear of being poisoned in the delusive paramour's interest, kill his wife in a fit of blind fury. Lennon, the New York murderer, under the influ- ence of similar insane ideas, cut up his wife in a regular checker-board pattern, and generally the crimes of these dangerous lunatics are as remarkable for their cynical bru- tality as their delusions are noted for obscenity. Besides the hallucinations related to the delusions of sexual mutilation, impotence, and marital infidelity, there are others of the same kind, as those found in acute alco- holic delirium: the patient sees mocking faces, snakes, insects, dead bodies, paving stones precipitated on him, and frequently will be found sustaining a dialogue with some absent friend, f and stop in the midst of conversation * This applies to the fully-developed disease only. f A chronic form of opium insanity which is in every respect analogous to chronic alcoholic insanity, the delusions of persecution being based on visions of supernatural instead of such of a se.\ual character, has been observed in three instances bv the writer. A marked feature of one of CHRONIC ALCOHOLIC INSANITY. 255 with persons actually present to answer those who are miles away or mouldering in their graves. Sometimes the hallucinations are of the character of a photopsia; one patient exhibited at Meynert's clinic saw lights streaming in through a closed door one night, and heard a confused noise (tinnitus) in the hall. In mortal dread of robbers and murderers he seized a hatchet in de- fence, fled from room to room, and finally feeling a head on a sofa, brained its possessor — his own father. The periods marked by anxious hallucinations are usually but imperfectly retained in the patient's memory; sometimes there is complete amnesia, and one fundamental difference between monomania and alcoholic insanity is the constancy •of some degree of enfeeblement of. the memory with the latter affection. Occasionally the sufferer from alcoholic insanity may be found in a state of stupor; but this differs from the superficially similar symptom of stuporous in- sanity in the fact that the patient can be readily aroused from it and made to answer questions. Chronic alcoholic insanity is more frequent in countries where spirits are consumed than where malt liquors or wines are chiefly used. It is in accordance with this fact that it is greatly on the increase in countries where the lighter liquors are being supplanted by the stronger ones. This has been noticed to be the case in Germany and France; regarding the latter country, Voisin reports the suggestive fact that while in 1856 only 99 patients suffering from the various forms of alcoholic insanity entered the Bicetre, in i860 the number had already risen to 207. It must not be believed that persons indulging in malt liquors and wines are exempt from alcoholic insanity. While this disorder is rarer here, quite typical cases have been observed by the writer in persons who never touched a drop of any ■other liquor. the cases, that of a physician, was the sustaining of dialogues with absent persons. It is remarkable that every form of alcoholic mental derangement is imitated by the opium psychoses. There is an acute opium delirium analogous to delirium tremens, a chronic delusional in- sanity due to opium like the form described in this chapter, and in one case, that of another physician, first treated at a private home for opium habitues, the writer witnessed an attack of maniacal furor which could in no respect at the time be differentiated from the exacerbations of paretic dementia. In the quiet period there were noted ataxic and paretic symp- toms. The patient recovered at Bloomingdale. This case is analogous to the alcoholic "pseudo-paralyses." 256 INSANITY. The prognosis of this form of insanity is very unfavor- able, as there is a pronounced tendency to dementia. Com- plete cures are rare, and if the affection has lasted any length of time, impossible. The higher the mental status of the patient the better are his chances, but asylum treat- ment must be instituted early if they are to avail him. In one case the writer has found that the delusions of marital infidelity disappeared under moral treatment and a reduc-- tion of alcoholic beverages at home, and a most interesting case of complete recovery from a delirious and hallucina- tory variety of alcoholic insanity has been recently reported by Sander.* CHAPTER XVII. Chronic Hysterical Insanity. Like epileptic and alcoholic insanity, the other main types of this division, hysterical insanity is found to be associated with a fundamental neurotic character. The patients are changeable, emotional, fretful, careless, and superficial in their behavior and thoughts; they are ex- tremely vain and egotistical, and desirous of notoriety or sympathy, or both. To be the sufferer from an equally interesting, rare, and hopeless nervous disease is the ambi- tion of some; to be considered the most abused woman on earth is the ambition of other hysterical patients. If the ordinary means fail to excite attention such patients will resort to extraordinary ones to excite sympathy. The imitators of Louise Lateau, who produced artificial stigma- tization, and the hospital patients who drove hundreds of needles into various parts of their bodies, are familiar in- stances of this fact. A patient of the writer's suborned her servants and nurses to give false testimony to the visiting physician; her vigorous fancy, a quality shared by her sisters in misfortune, enabling her to sustain their asser- tions with an appearance of truthfulness and conviction which at the time was real. There is no doubt that the " tale told too often" is finally believed in by the patient, * Psvchiatrisches Centralblait, Aug. and Sept., 1877. CHRONIC HYSTERICAL INSANITY. 257 and that the potent influence of the mind over the body must be looked to, to explain why material and objective symptoms appear subsequent to the pretence being made. A patient with this hysterical character may develop psychoses quite analogous to those found in epileptic and alcoholic patients. Just as we have transitory epileptic psychoses, so we have a transitory hysterical psychosis manifesting itself in deliria of fear. Just as we have mani- acal and melancholic states with epilepsy and alcoholism, we have them in hysteria, and similarly we find a protracted psychosis in hysteria analogous to the alcoholic disorder discussed in the last chapter. A tendency to simulation and theatrical behavior is characteristic of these various forms of hysterical disorder. They are particularly marked in the chronic form of de- rangement about to be briefly considered. In chronic hysterical insanity an intensification of the described hysterical character is the most constant feature, a silly mendacity is frequently added and develops pari passu with advancing deterioration. Sexual ideas are com- mon and manifested in two opposite extremes: either there is excessive sexual ardor, which may be so intense that the patients experience the orgasm spontaneously, or — and this is in the writer's experience far more common — there is an absolute horror of anything that remotely suggests the sexual act, a feeling which is the basis of a hatred of the husband frequently exhibited by these patients. Hallucinations are frequent, and usually of the kind described by Wundt as fantastic hallucinations. They are analogous to the hallucinations of hypochondriacs, being the outcome of the patient's fancy and fears. In the case of one patient, who was an excellent artist, visions of countless lovers in the costumes of all ages and peoples interspersed with horrible visions of hell, with all the para- phernalia attributed to that region by the older masters, were the most prominent symptoms. In some cases these visions and analogous illusions provoke ecstatic and vision- ary states. Krafft-Ebing says: " On this basis there develop deliria of a mystic union with God and of celestial visions. The patients see heaven open, indulge in enthusiastic preaching, speak in strange tongues, prophesy, etc." This applies to the episodial deliria of monomania with a hys- terical tinge, and not to hysterical insanity proper. Here there may be found ecstatic states, but they resemble rather 258 INSANITY. the deliria of hystero-epilepsy than the visionary deliria, and where such ideas and acts are found in true hysterical insanity as those described by Krafft-Ebing they are like those of the hysterical insane epidemics of the middle ages, imitatory phenomena. In some patients obstinate mutism is observed. By skil- ful cross questioning it will be speedily found to be wilful; a comical series of questions will make a patient who has not winced under the wire brush smile; the suggestion of a vaginal examination will make her blush; and a skilfully provoked petulant answer to an invidious remark will demonstrate the patient's simulation. Illusional transformations of sexual sensations are a fruit- ful cause for insane ideas in hysterical lunatics. Most of the accusations of rape made against physicians and den- tists, and of almost daily occurrence in asylums, are made by insane hysterical patients. The prognosis of this form of insanity is unfavorable as to the ultimate termination of the case. Temporary re- coveries are noted and are as suddenly established as many of the other transformations of the hysterical state. But a recurrence is very probable, and with each recurrence de- terioration becomes more marked. CHAPTER XVIII. Epileptic Insanity. Most of our psychiatrical and medico-legal authors, in discussing the medical or legal relations of epilepsy and epileptic insanity, limit their attention to, firstly, the con- dition called epileptic mania; secondly, to epileptic demen- tia, and, thirdly, to the peculiar change of character which many epileptics manifest. This series is, however, far from perfect, and fails to in- clude many important conditions which are allied to and dependent on epilepsy, and which, on the one hand, may require special medical treatment, and, on the other hand, merit the serious attention of every thorough and conscien- tious medical jurist. EPILEPTIC INSANITY. 259. It is an opinion quite prevalent with many, that the epileptic, unless chronically demented, and aside from the period just preceding and following the attack, and the at- tack itself, is always sane from a medicah and competent and responsible from a medico-legal point of view. This view is held by many general practitioners of medicine, and by most English medico-legal writers. On the other hand, there are those who, as soon as they find the slightest in- dications of epilepsy in the person under investigation, instantly jump at the conclusion that, ergo, that subject cannot be of sound mind or responsible for any transaction performed by him. This view, as the reader will already have anticipated, has had its origin among those who have been or are frequently called by the defence in criminal cases, where insanity is the last resort of the defendant. Both views constitute utterly erroneous extremes, but they are not only erroneous, they are and have been damaging to the cause of justice, inasmuch as interested or possibly unscrupulous medical witnesses have been able to fall back on such views enunciated in published works, in support of testimony which has too often defeated the true purpose of the law. Aside from epileptic dementia, a mental degeneration which is intimately dependent on the frequency of the con- vulsive attacks, and which, as Esquirol has graphically de- lineated, may determine stupor, imbecility, or actual idiocy, according as these attacks begin later or earlier in life, aside also from those attacks of furious madness, or purposeless automatism ;r//d;^/«^ the convulsive attack, and which may be regarded a s psychical equivaloits of the convulsion, there are forms of more or less protracted insanity which follow some individual epileptic attack or break out in the interval, or finally extend over the entire interval, which are to be- strictly distinguished from these forms. It was the observance of the new forms, without any dif- ferentiation from other varieties, that led Calmeil to say that those epileptics not yet insane are very irascible, very impressionable, inclined to false interpretations, and to ex- aggerate the importance of petty affairs. This description is probably based on cases of commencing intervallary alienation, and it would be erroneous to extend it to most epileptics living without asylums. The same remarks apply to Baillarger's statement, that the characteristics given by Calmeil often precede the outbreak of complete insanity.. 260 INSANITY. Both these authors seem to have distinguished but imper- fectly between actual intervallary insanity and the ordinary change of character discovered in the interval. Delasiauve has also doubtless confounded ordinary epileptic dementia with post-epileptic or intervalrary conditions when he speaks of patients afflicted with " stupidite des epileptiques" as performing automatic acts, looking like drunken men, etc. Falret opened the way for a rational classification with the following dictum: "A remarkable phenomenon which frequently complicates the incomplete attacks of epilepsy, or the interval between two perfectly developed attacks, deserves mention. The patient seems to have come to himself; he enters into conversation with the persons who surround him, he performs acts which appear to be regu- lated by his will, and seems, in one word, to have returned to his normal state. Then the epileptic attack recommences, and as soon as it has ceased and the patient has recovered his reason, it is found, to one's surprise, that he has not preserved any recollection either of his words or acts which were said and done in the interval of the two attacks." Under the head of " Petit mal intellectuel" (not to be confounded with petit mal ordinarily so called), the same author describes a condition which ma .y continue for several hours or sever ST days alter the post-epileptic stupor has subsided, in which the patient becomes sullen, deeply de- jected, very irritable, and feels an utter inability to fix his thoughts or to control his will. Under the head of the " Grand mal intellectuel" he de- scribes an analogous but longer lasting condition coupled with alternate stupor and attacks of furious excitement. As Samt correctly remarks, the recognition of these forms was an important step in advance; but these do not exhaust our knowledge of the possible forms of post-epilep- tic insanity. He includes both X\\& petit mal andi grand mal intellectuel of Falret under the head of acute post-epileptic insanity, and defines the latter as insanity immediately fol- lowing the convulsive paroxysm, and taking an acute course. He subdivides this acute form into: ist. Simple post-epileptic stupor, which may be complicated with dreamy deliria, or with illusional or hallucinatory con- fusion and verbigeration. 2d. Post- epileptic jnorbid conditions of fear or fright, either simple or complicated with de'lire raissonante or great excite- ment. The latter form corresponds to Falret's grand mal EPILEPTIC INSANITY. 261 iiitclkctuel. While stupor is usually present in this form it may be so far in the background that some of the cases under this head merit being characterized as cases of par- tial "frightful " post-epileptic delirium. 3d. Post-epileptic Maniacal Moria. — This form is rare, and simulates ordinary acute mania to such an extent that even the expert may be deceived. It is only the irascible char- acter of the mania and the suspicious manner of the patient, and, as the writer believes, the treacherous and malicious character of his violence, which enable one to distinguish this disorder from the ordinary attacks of the acute maniac, who, under appropriate associations, is good-natured and manageable, aside from his episodical furor. Under the head of chronic protracted epileptic insanity he describes many cases which are evidently related to the post-epileptic forms. On the other hand, the writer has observed some cases in which gradually increasing verbi- geration, delirium of a religious tinge, or maniacal attacks with or without intervals of stupor, confusion, and automat- ism, preceded the outbreak of a convulsion or its equivalent. Just as the forms characterized in Samt's classification were designated post-epileptic, these latter, noticed by the writer and which are far from infrequent, deserve being designated SiS prodromal or pre-epileptic. If the chronological relation of the mental disturbance be made a principle of classification, much confusion could be avoided by adopting the following: 1. The epileptic psychical equivalent, which replaces the convulsive attack. 2. The ACUTE POST-EPILEPTIC INSANITY, wliich almost im- mediately follows the convulsive attack (including the ordinary post-convulsive stupor as a part of the attack), or similarly succeeds the psychical equivalent of such con- vulsive attack. Samt states that he has observed a similar condition in connection with epileptiform uraemic convul- sions in two cases.* 3. The PRE-EPILEPTIC INSANITY, whicli prcccdcs the out- break of a convulsive attack or its equivalent, and increases up to the moment when the paroxysm explodes. 4. The purely intervallary epileptic insanity, which, neither immediately following nor preceding a paroxysm, occurs in the interval between such. It is possible that all such cases are, after all, equivalents of imperfect convulsions, * Archiv. f. Psychiatric, vi., p. 143. 262 INSANITY. but as long as the relation cannot be clearly established it is well to provide a category for the reception of such doubtful cases. It is possible for all these forms to occur together, and in addition there is very apt to be a background of protracted epileptic dementia to complicate the picture. It is only when epilepsy is recent that the above forms are found in an unmixed state; as the disease progresses we are very apt to find that the post- epileptic grand wa/ i/if^/Zectue/ oi Falret and Samt is in intimate association with a " replac- ing" attack of violence. Such cases, lasting with their correlated stupor, delirium, and confusion for entire weeks, figure as " epileptic mania" in our asylum records. A very marked case of the grand nial intcllcctuci, occur- ring in a recent case of epilepsy, interesting because of its mal-recognition and subsequent termination, and wliicli came under the w-riter's notice, may illustrate some prom- inent features better than any hypothetical description. From the history it is evident that pre-epileptic insanity had been also present. On the 29th of December the writer was hurriedly called, in the evening, to a police officer wlio was stated to have " fits" at his residence. On arriving, he found the patient, a powerfully built man, standing up in the middle of the room, his relatives holding him. The patient was muttering unintelligibly, but recognized that a stranger had come in, though supposing, at first, that the latter was the police surgeon of his precinct, with whom he was personally well acquainted. As the number of persons surrounding him, with the intention of restraining him, was evidently a source of excitement, the writer ordered all but a few to leave, and, slapping him on the shoulder, told him every- thing would be "all right" if he would sit down. He obeyed in a dazed and bewildered manner. During con- versation with him he seemed to awaken out of his dreamy state several times and then would attempt to arise, but could be easily prevented by manual restraint and would speedily forget his intention and continue the interrupted conversation. He looked suspiciously and furtively around, and seemed to be suffering from a general oppression and vague fear. His pupils were moderately dilated and the face considerably congested. To an ordinary beholder he would, for considerable periods, give the impression of per- fect mental equilibrium, speaking about the details of his EPILEPTIC INSANITY. 263 duty and the personalities of higher police officers in a quiet, deliberate, and apparently intelligent manner. But he seemed to enter into such conversation more with the idea of getting rid of the questioner, and of the restraint which was imposed on him to prevent his sallying forth to the street. He was dressed in a morning gown, but had thrown his police coat over it and put on the police hat and was trying the different doors, from which the writer had had the keys removed after locking them. He then endeav- ored to go out of the window, laboring under the idea that, as he would be dismissed from the force if absent continu- ally from duty, he had to get out of the house somehow. It turned out that all this time his diseased condition had been recognized at headquarters, and he had, to his own knowledge, been excused from duty several days previous. He now became violent, but still discriminated between the members of his family, whom he treated both with physical violence and profanity, and the physician, whom he treated with profanity only. When his wife reminded him of his discourtesy, as a i-iise to divert his attention from his ideas of escape, he said, "Oh, , the doctor knows how it is himself." One of the children whispered to the other to close a door which had not been locked. He seemed to hear this and started for it. The writer followed and closed with him to prevent his passage. In attempting to over- come the obstacle which was made to his passing he fell down ; then he said, "Very well, I knew I was going to be murdered," and could not get up till the writer assisted him. The writer turned him right about in raising him and the patient continued his search for the open door, but went in the opposite direction and returned to the room from which he had started without noticing it. He became considera- bly excited about the absence of his shield and watch. His wife refused to say anything about them for fear that he wanted them to go on his imaginary duty with. He be- came more and more excited, but would pass to other top- ics, and rested in the chair from physical weakness, having fallen to the ground on several occasions. When his wife told him that she had his watch and shield he seemed sat- isfied, and began to talk as if he were in the station house, spoke to the writer as if he had been one of his colleagues, and related incidents and arrests in a wearisome, mo- notonous way. It was found now that his tongue was tremulous and deviated to the right side, the facial muscles 264 INSANITY. of the left side were more firmly contracted than the right, but there was no noticeable facial deviation. He again wanted to go out with his hat and in a red shirt, and had entirely forgotten the fact that he had been excused from duty, as was shown by conversation. The sedative which had been ordered now arrived, and the writer readily induced him to take sixty grains of bromide of sodium with five grains of chloral. After fifteen minutes he seemed a little more rational, recognized that he was at home, and was induced to go to bed, after it was proven to him that it was night and not noontime, as he was supposing. His previous history was as follows : Half an hour before he had been visited, he had, while standing, "suddenly craned round" on his left side, his head " twisted " to the left, his eyes " rolling" in the same direction, and he was " perfectly stiff," then he had violent spasms, and "worked" with these several minutes; after "a short spell" he got up and acted as if drunk, con- tinuing to manifest similar symptoms to those which are above described, but had one attack of furious violence be- fore the writer came. Two days previous (the 27th) he had been relieved from duty and sent home, under some pre- text, as it was not easy to reason with him. That he had had an attack of mental confusion was evident, as one of his brother officers subsequently delivered the watch and badge to his wife. He was "fiighty" on arriving home, and on several occasions supposed himself at the police station instead of at his house, and reproached his wife with being in the officers' waiting room, and counselled her to go home. On previous occasions he had suffered from violent neural- "•gia, wh ich increas ed in severity until he became unconscious - gf stupid, a tjgj^jy nicn, tne n euralgia cjisappearuT g. he be ^ came aelirj ous! This had occurred within the last five years probably a"3ozen times, but the only pronounced epileptic attack which he had had was the one following which the writer saw the patient. He had been a drinking man, and the police surgeon had made the diagnosis " alcoholism." During the night, after receiving the sedative, the patient slept fairly, but awoke twice, and on one occasion went into the street to patrol, and was brought back by another policeman, and the police surgeon again took charge of him. The writer saw him the following morning, but did not treat him, as his regular attendant had seen him shortly before. The patient was found half undressed, eating his breakfast, his face extremely turgid and congested, his EPILEPTIC INSANITY. 265 mind very much confused. He could enter into ordinary conversation for a few moments consecutively. So far the writer's observation went. Having occasion to attend an- other member of the family, he learned that the case had terminated in a very abrupt and unexpected manner. The patient went out in full uniform at ten o'clock of the second morning following and patrolled Fiftieth and Fifty-first streets, without exciting any attention, his behavior not appearing strange at all. His actual "beat," however, was Grand and Houston streets, three miles distant, and toward noon he went to Fifty-third Street, stating it to be Grand Street. The police surgeon had, meanwhile, ordered him to be taken to a certain hospital. This was accomplished by deception, a neighbor getting him to arrest her little boy, whom he took to the hospital in triumph. Once there, he was placed in a strait-jacket and breathed his last in this apparatus that same evening.* This was a case in which pre- and post-epileptic insanity were combined. Other cases differ only in exhibiting either more violence or some predominant delusion or hal- lucination. The writer may refer, as an example of pre- epileptic mental disturbance, to the case of a little girl described in an earlier journal article, who manifested an hallucination which gradually increased in intensity until the convulsive paroxysm exploded. In this instance the hallucination finally became intervallar)'-, and disappeared entirely with the disappearance of the epilepsy. The following case illustrates the career of an epileptic, marked b v numerous characteristic attacks of epileptic in- sanity . Dating from his thirty-ninth year, the patient, a prosperous and intelligent business man, for the fifteen years of his remaining life ^had epileptic convulsions at intervals of from one week to several monTRsT His business asso- ciates observed that he forgot important business transac- tions, claimed to have signed vouchers which he never had ■signed, did not recollect having signed others which he had signed, and became abstracted and dreamy, on one occasion undressing in the office. Several years prior to his death he voluntarily relinquished the responsible position he had occupied for an humbler capacity in the same business. For some days following each epileptic attack he was unable * According to the family, the marks of the strait-jacket were plainly visible on his body, the skin being chafed and cut in many places. 266 INSANITY. to attend to his business affairs, and this became more and more noticeable as time advanced. On one occasion he had an outbreak of furious mania, breaking and destroying^ everything within reach; this was followed by a state of alternate excitement and stupor, he yelled that he was being murdered, that people were setting the house on fire, and it required the force of several men to hold him in bed ; he, on one occasion, got out on the staircase in his night-shirt under delusion of mortal danger. This lasted for sev- eral days, when he was transported to the lunatic asy- lum. The coach driver induced him to enter the car- riage under pretext of taking him out for a drive. When he entered the asylum he was indifferent with reference to the trick played upon him. This indifference is a characteristic feature of epileptic insanity, of this vari- ety. Later he was alternately clear and excited, at other times in a drowsy condition. After an asylum sojourn of thirteen days he left the institution physically improved, but in a dazed and dreamy state. In the signature to a will, made a few days later, extraordinary tremulousness and irregularity were manifested. The lines were broken, one " s" looked like an " e," the scrawl was almost illegible, and the name " George" appeared as if it had been written Georger" or "Georgia." His ordinary handwriting was a good, clear, average business hand, and he had been in the habit of signing himself " Geo.," abbreviating the " George." In the signature there was a gap and covered- up break be- tween the first three letters and the last three, as if the dece- dent had started to write his usual abbreviation, and com- pleted the full name, probably on suggestion. Nineteen days after making this will he w'as readmitted to the asylum after another attack of violent insanity similar to the one preceding his first admission. The same coachman drove him to the asylum under the same old pretext of driving him to Coney Island. On his reception in the asylum he was found stupid, presenting marked tremors, and for sev- eral days he had to be fed with the stomach pump, he re- fusing food under the delusion that he was being poisoned. His tremor continued, gradually increasing, while his stu- por deepened to coma, and he died six days after his ad- mission. The immediate prognosis of epileptic insanity is favor- able as regards the more acute explosions. The protracted forms are sometimes recovered from, but here mental en- PERIODICAL INSANITY. 26/ feeblement is more likely to ensue than in the former. The safety of society demands that epileptic subjects should be under some surveillance after being discharged from an asylum, for the epileptic psychoses may break out with great suddenness and lead to the most deplorable results at any time. CHAPTER XIX. Periodical Insanity. Periodical Ifisanify is characterized by the recurrence of mental disorder at more or less regular intervals; the attacks being sepa- rated by periods during which the patient presents a state of ap- parent mental soundness. Periodical insanity is in most cases what Krafft-Ebing terms a degenerative insanity, being the manifestation of an hereditary or acquired vice of the constitution, and shares the bad prognosis as to recovery with other degenerative disor- ders, such as monomania and epileptic insanity. Like these forms it is, in the vast majority of the cases, hereditary, and may in exceptional instances arise after an injury to the skull, or from prolonged alcoholic excesses. Occasionally the out- breaks of the disease are coeval with certain physiological periods ; this is notably the case with those periodical de- rangements of females, which either precede, concur with, or follow the menstrual period, and which are sometimes des- ignated as menstrual insanity. Inasmuch as the menstrual condition is not the true cause of this insanity, but merely an exciting factor — the real cause beingthe hereditary neuro- tic vice — menstrual insanity cannot be considered a separate clinical form; in the majority of cases it is only a variety of periodical insanity whose periods coincide with and are de- termined by menstruation. There are other mental disor- ders in females influencd by menstruation, and the accepta- tion of the term "menstrual insanity" would hence involve much confusion. The general feature in which all the periodical insanities agree is, as indicated in the definition, their more or less regular recurrence; a recurrence as marked as, and in many respects analogous to the recurrence of epileptic fits. Just 268 INSANITY. as the epileptic fits are merely the periodical exacerbations of a deeper constitutional condition — the epileptic state; so the attacks of periodical insanity are the manifestations of a chronic morbid state of the brain. And-where this illness is not the expression of an hereditary taint, it is provoked by such causes which, like traumatic injuries and alcoholic ex- cesses, may imitate the evil effects of heredity, and artificially produce a disposition to nervous and mental disease. The regular recurrences of the morbid explosions in peri- odical insanity have induced not only the ancients to sus- pect a relation between them and the influence of the lunar changes, but within the year a German alienist (Koster) has published an elaborate treatise to prove that this recur- rence is in periods of seven days or in multiple days of seven, determined by the apogee and hypogee of the moon. There may be a dependence of this kind, but the writer is unable to consider it a direct one, but rather as one possibly determined by the general bodily condition at such periods. Barometric and seasonal variations appear to exercise a much more palpable influence on the outbreaks of periodical insanity. The theory that periodical insanity is the expression of a degenerative taint is supported first by statistics, inasmuch as the majority of the patients have a bad fam.ily history; secondly, by the frequency with which somatic signs of de- generation, cranial anomalies, and other evidences of dis- turbed development are found in them; and thirdly, by the fact that the beginning of the disorder coincides with cer- tain physiological periods, such as puberty and the climac- tenic, while its exacerbations often follow other physiologi- cal periods, such as menstruation; this, it is now generally admitted, is a feature of the degenerative psychoses. A very important characteristic of periodical insanity is the similarity of the manifestations in the different at- tacks with the same patient for long periods. Whatever form one given attack takes, that form is destined to charac- terize the subsequent attacks for many years. The earlier attacks are sometimes abortive and do not resemble the later ones; and, as the disorder progresses, the attacks be- come, as a rule, more severe ; but for any period extending over a number of years the attacks are so similar, that the same morbid propensities, the same imperative conceptions and impulses, the same delusions, hallucinations, nay, the same insane language, occur with a regularity which is not PERIODICAL INSANITY. 269 the least Striking feature of periodical insanity. This is not unlike what is sometimes observed in epilepsy,where for long periods the same aura, the same form of attack, and the same post-epileptic plienomena are found with each explo- sion. It is not without some bearing on this similarity that the sufferers from periodical insanity — at least in the experience of the writer — show epilepsy in the direct and collateral family lines more often than other insane patients do. The intervals between the periodical outbreaks are not alwa)'s entirely lucid, but rather sub-lucid. The patients are reasonable, capable of attending to their affairs, and a few may exhibit nothing abnormal even to an experienced alienist. But most are what is called "nervous/' the fe- male patients particularly are apt to be markedly hysteri- cal, and a morbid irritability is quite a common feature. In advanced periodical insanity the patients exhibit a per- manent change of character; they become indifferent, their emotions are blunted, their mental energies decrease, and morbid irascibility becomes more prominent. In this res- pect there is another close resemblance between the epileptic neuroses and the periodical psychoses, for while in the earlier periods of epilepsy the inter-epileptic states may present nothing noticeably abnormal, as the disease progresses an epileptic change of character usually becomes a more and more marked feature of these intervals. With the exception of certain cases classed as circular in- sanit}', the inception and termination of the periodical out- breaks are more abrupt than in simple mania and melan- cholia, which these outbreaks may otherwise resemble. In addition the deliria if present are apt to be of a reasoning character, while moral or affective perversion, and certain propensities and impulses not ordinarily found in the simple insanities, serve to indicate the character of the disorder. Aside from these signs it is only the history of the case, re- vealing the periodical recurrence of similar attacks, which serves to justify a diagnosis that the disorder is probabl}^ a periodical one. Periodical Mania generally begins abruptly, though sometimes it is inaugurated by a brief period of depression. More frequently signs are observed which Krafft-Ebing happily compares to a pre-epileptic aura : the heart pal- pitates, while vertigo and fiuxionary head symptoms and neuralgic signs are precursors of the maniacal explosion. 270 INSANITY The latter is marked by angry rather than pleasant excite- ment, by moral perversion rather than by sanguine exal- tation, and by what the French term delirc des actes; namely, a tendency to continuously perform acts impulsively, such as sexual excesses, indecent assaults and exposures, alter- nating with thefts, incendiarism, and errabund * tendencies, rather than by the ambitious, teasing, and jocose acts of simple mania. In females the tendency to cast aspersions on other females is pronounced, and almost characteristic. With these symptoms, which are termed deliria of acts, occasionally hallucinations, more commonly illusions, and rarely delusions, may be added, there are frequent out- breaks of angry excitement, and these are of a violent and dangerous character. They are sometimes provoked by the alcoholic excesses to which periodical maniacs are so likely to resort; and it is observed, even in the free intervals of periodical mania, that alcoholic beverages are not borne well, a moderate indulgence leading to disproportionate disturbances of consciousness and of the will power. Instances are recorded where a single morbid propensity has been the most prominent and constant feature of peri- odical mania. Certain sexual aberrations (p. 40) are par- ticularly apt to be manifested in this way ; as in the case of a lady observed by the writer, who exhibited violent fits of jealousy, in one attack leading to a sanguinary suicidal attempt growing out of a sexual perversion of a platonic character. Most of those patients described as kleptoma- niacs are periodical maniacs, in whom the propensity to steal predominates over the ordinary symptoms of mania. From the cases of periodical mania in which kleptomaniac and other morbid impulses predominate over exaltation, the transition to those forms in which the morbid impulse is the sole manifest symptom is natural. Almost any one of the known forms of morbid impulse may appear in periodi- cal phases, but this is particularly the case with the morbid craving for drink, which seizes on its subjects at certain in- tervals with such intensity that the ordinarily quiet, or- derly, refined, and sensitive patient, losing all sense of pro- priety and shame, gives himself up to unrestrained and ruinous debauchery. This distressing condition is known Mauia crrabunda is a term which has been indiscriminately applied to periodical, pubescent, and paretic insanity whenever the tendency to roam about aimlessly has been a marked, however temporary, feature of the insanity. PERIODICAL INSANITY. 27 1 ^s BIPSOMANIA. It is to be distinguished from inebriety and alcoholism; for the inebriate is not driven to his ex- cesses so suddenly and irresistibly, nor does he cease them as abruptly, as the dipsomaniac. In the inebriate the motive grows out of appetite and habit ; in the dipsomaniac it is a blind craving which, if it is not stilled by alcoholic bever- ages, will seek some other outlet. Often these patients de- velop a morbid craving for certain narcotics, and we may thus have a periodical craving for opium analogous to the periodical craving for drink, and as distinct from the ordi- nary opium habit as dipsomania is from inebriety. As a consequence of his blind indulgence in drink during his diseased periods the dipsomaniac may become the sub- ject of acute alcoholic delirium, or of chronic alcoholism, though the latter is rare; these conditions are to be looked upon as results, and not as essential features of dipsomania, which is to be defined as a form of periodical insanity jnani- festing itself in a blind craving for stimulant and narcotic bever- ages. The relationship of dipsomania to the other periodical neuroses is well i Ilustrated by the instance — not to go beyond cases already cited — of the lady suffering from periodical exacerbations of sexual perversion, who had a father and two brothers dipsomaniacs, and one sister suffering from periodical neuralgias, another from periodical gloomy spells. Periodical Melanxholia presents no distinguishing marks from ordinary melancholia in its individual attacks. Its periodicity is its sole criterion. It is worthy of note that periodical melancholiacs are the most persistent, cun- ning, and successful of all suicidal lunatics. Periodical insanity does not always manifest itself under the guise of a single form of derangement. There is a sub- division known as Circular Insanity {cyclothymia) which is characterized by the alternation of mania and melancholia in reg- ular recurring cycles. In the marked cases, for example, a profound melancholia is followed by a violent mania, this by a lucid interval, and then the melancholia, mania, and lucid interval return again and again, in the same order, comparably to the succession of the cold, hot, and latent stages of an attack of intermittent fever. In some cases there is no free interval, the mania begins when the melan- cholia ends, and the latter is immediately followed by mania. This is the variety to which Falret first applied the term folie circtilaire ; while Baillarger subsequently dis- tinguished those cases in which a more or less perfect and 2/2 INSANITY. prolonged lucid interval is interpolated under the designa- tion folic a double forme. The order of each cycle varies in different patients : the mania may precede the melancholia or vice versa. Both may be of a mild type, and both may be very severe; or one may be slight and the other intense. A furiburid mani- acal attack may open the scene and be followed by a mild depression; and a simple exaltation may be succeeded by a profound melancholia, with anxious delusions, hallucina- tions, and suicidal inclinations. On the other hand, a mild melancholia, not exceeding the limits of a moderate degree of inertia, may be followed by violent agitation and de- structiveness; while a melancholia, so intense as to approach the degree of cataleptic stupor, may give way to a sanguine exaltation of spirits, scarcely meriting the name of a mania. It is such cases as the latter which constitute connecting links with the ordinary forms of periodical insanity above considered. As a rule the mania and melancholia correspond to each other in intensity. Where the cycle is of brief duration, lasting a few days or weeks, both are apt to be very well marked; where it is of a duration of months both are apt to be of a mild type. In some cases the patients seem to be oscillating between extreme moods, which show an alter- nation like that of circular insanity, throughout their life- time; for weeks and months such subjects are sanguine, lo- quacious, energetic, indulging in expensive and ambitious schemes, and then during the next few weeks or months they are just the reverse; they seem deprived of all hope, are taciturn, inactive, regret their extravagances, and undo what they have undertaken. Such individuals are a con- stant source of anxiety to their relatives, and of danger to themselves. It requires but a slight circumstance to lead them to the wasting of their fortune, to other extravagant acts, or to develop an attack of furious frenzy, during the exalted period; while during the period of depression they may allow a flourishing business, undertaken in the exalted mood, to go to ruin from inertia, or even commit suicide. It is in cases of this kind that we are least likely to have a lucid interval. Where the maniacal and melancholic stages are most clearly marked, on the other hand, we may find an equally well marked period of unquestionable mental health separating the morbid periods. Instances are related where a patient has been maniacal one day, melancholic the PERIODICAL INSANITY. 273 next, lucid the day thereafter, then maniacal again, and so on. The writer believes such cases to be exceedingly rare, the shortest cycle he has seen in over fifty cases lasted from ten to twelve days, and ordinarily each stage covers from a week to a few months. It has been noted that in some cases the alternation corresponded to the seasons: the patients being melancholy in winter, maniacal in spring, and lucid during the summer, developing melancholia again in the fall. As a general rule — not, however, without numerous ex- ceptions — the shorter the cycle the more intense are the symptoms, and the better also are the prospects of the case. Some German observers have found that the patients gain in weight during the maniacal, to lose in weight in the mel- ancholic period; but this is not a constant phenomenon. The differential diagnosis of circular insanity can usually be made only by learning the history of the case. The char- acteristic feature which serves to distinguish it from other forms of insanity is the alternation of the opposed conditions of mania and melancholia, and this alternation can be glean- ed only from the history, or detected by keeping the patient under prolonged observation. During the maniacal stage, as a rule, it is impossible to discover any difference from an ordinary case of simple mania, while during the melancholic stage it is equally impossible to recognize any feature not to be found in simple melancholia. That it is of the highest importance to discriminate be- tween an ordinary mania or melancholia and the maniacal and melancholic phases of circular insanity, must become evident when it is borne in mind that the prognosis in the former affections is in the highest degree favorable, while in circular insanity it is most unfavorable. In some cases, the mania and melancholia may present a "reasoning" character, and thus lead to the suspicion that the insanity is circular aside from the confirmation furnished by the history. But even the observation of an entire cycle does not establish the existence of this form of insanity; for it is well known that a simple mania may be preceded by de- pression, or pass to recovery through a stage of stupor, and thus resemble such a cycle. It requires the demonstration of several cycles to make the diagnosis of circular insanity complete. We have further strong reasons to suspect the existence of this disorder, if during the free interval the patient is 274 INSANITY. noticed to be morally perverse. As in periodical insanities, generally, the lucid, or rather sub-lucid, intervals of circular insanity are often marked by anomalies of character; we find these patients in these periods of this disorder to in- trigue against their surroundings merely for the love of intrigue and the delight which they experience at annoying others. Neither the true maniac nor the melancholic pa- tient ever manifests this. The former delights to tease, but usually in a good humored way, not from malicious incli- nations ; the latter prefers to be let alone. Occasionally we are aided in our diagnosis by narrowly watching the transition between the mania and melancholia. Usually this transition is very abrupt and complete; the patient goes to bed melancholic and rises maniacal; it is uncommon for the maniacal and melancholic symptoms to balance each other, so as to constitute a para-lucid tran- sition. Circular insanity generally begins at or about the age of puberty, is, like other periodical insanities, more frequent with females than with males, is intractable to treatment, and while it does not ordinarily lead to dementia, some mental deterioration is manifested in its subjects sooner or later. The reported cures are few, and, as far as can be gathered, the diagnosis was not well established in the ma- jority of these. It is to be borne in mind that the hysteri- cal psj'choses as well as malarial neuroses may exhibit an exquisite circular type of insanity. The writer has seen this latter phenomenon, and succeeded in controlling the dis- order with quinine and calomel; but he regards such a case as a cured malaria which manifested itself under the mask of a cyclical insanity, and not as a true cyclothymia, which is the expression of an essentially cerebral and deep- ly-rooted vaso-motor neurosis. As previously stated the periodical insanities are more frequent in females than in males. Among other causes which account for this difference in the sexes is the fact that uterine disorders frequently act as exciting causes of the malady in predisposed subjects ; this may account for the few reported cures effected by gN'naecological treat- ment. Of 2,297 male pauper patients, the author found five per cent suffering from periodical and its sub-group circular insanity. Unfortunately some cases of so-called " recurrent mania" were included in the computation, so that the correct figure would probably be nearer four per cent. THE STATES OF ARRESTED DEVELOPMENT. 2/5 CHAPTER XX. The States of Arrested Development. By many the conditions known as idiocy, imbecility, and cretinism, iiave been considered to occupy a position sepa- rately from insanity proper. To-day we know that the typical psychoses of the neuro-degenerative series may arise on the basis of the same or similar developmental defects as those which are so characteristic of the states of arrested and perverted development. We also know that this fact is in harmony with the observed " transformation" of the ordinary forms of hereditary insanity into idiocy and imbecility in the course of hereditary transmission; and that the clinical manifestations of the latter are sometimes in the same direction as those of insanity proper. For all these reasons it appears inexpedient to make a sharp sep- aration. It is customary to distinguish three grades in this group. To the subject deprived of all higher mental power, and who is unable to acquire the simplest accomplishment, the term idiot is applied. He who is capable of acquiring simple accomplishments, but unable to exercise the reason- ing power beyond the extent of which a child is capable, is designated an imbecile. Finally, there is a large class of subjects who are defective as to judgment and in whom this defect is of similar origin to, though not as intense as, that of the imbecile and idiot, who are termed feeble- minded. There is a complete series of transitions, beginning at the lower end with the non-viable anencephalous monster and passing up through the brain-monstrosity, the microcepha- lus, the idiot, the imbecile, and the feeble-minded, to the normal person. This transition is at once structural and physiological. In idiocy there is usually, in addition to the mental defect, some deficiency in the peripheral organs or their functions. Many idiots are deaf or mute or both, some are blind, and anaesthesia as well as anosmia have been observed. They learn to walk late or not at all, and those who learn to walk have a shambling, shuffling gait, which, in the case of the microcephali, is said by Vogt to resemble the mode of 2/6 INSANITY. progression of the anthropoid apes when erect. The skel- eton is usually poorly developed, rachitis is common, and the somatic functions generally are imperfectly performed; the sexual organs particularly are found to be rudimentary or deformed. On comparing a large number of idiots the reflection forces itself on the observer that three different sets of causes of arrested development are active in producing this condition.* In some cases we find that one of the parents of the idiot has an abnormal cranial shape or premature ossification of the sutures, and is himself or herself insane, epileptic, hysterical, or feeble-minded. Here a transmission and intensification of the ancestral defect is to be assumed to have taken place. In another group of cases we find that the parents were originally mentally healthy, but that the foetus has been injured or has acquired some constitu- tional vice, such as syphilis in utero, or suffered from some brain disorder such as epilepsy, eclampsia, or meningitis in infancy. Ireland has found idiocy resulting from brain disease as late as the tenth year. In the third group, the smallest, an atavism, that is, a reversion to the hypothetical ancestry of man, has been suspected. This claim of scien- tists must not be confounded with the paradoxes involving formally similar views which best flourish in a soil untilled by either anatomical, physiological, pathological, or clinical observation. It is a fact which may retain some degree of that same historical interest which, as the writer has stated, he believes will cling to the views emanating from the laboratory of the Utica Asylum (page 96), that a recent course of demonstrations, in which the superintendent furnishing them got over the entire ground of insanity in four lectures,! called into being the following gem of com- bined psychiatry and zoology: *Dr. Ireland classifies idiocy as followft i. Congenital. 2. Micro- cephalic. 3. Eclamptic. 4. Epileptic. 5 . Hydrocephalic. 6. Paralytic. 7. Cretinic. 8. Traumatic. 9. Inflammatory. 10. Due to depriva- tion of the senses. The microcephalic idiots are always congenital idiots, while paralytic idiocy is really mental impairment from organic disease, and, as the subject may regain mental power, should not be classified with idiocy. The last group is not a real idiocy, any more than Casper Hauser was an idiot, because he had had no opportunity to learn. f Clinical Lecture on Dementia. Idiocy, and Imbecility: being the third of a course of four lectures upon the diagnosis of insanity. Delivered at the New York City Lunatic Asylum, Ward's Island, by A. E. Macdonald, M.D., Medical Superintendent. — A'. Y. Medical Record, Dec 20, 1879. THE STATES OF ARRESTED DEVELOPMENT. 2/7 " Here is a negro whose feet look as if they were formed to clutch the limb of a tree, and it does not require a great stretch of the imagination to picture his ancestors, in no very remote generation, jumping from limb to limb of some African forest. " And with this return, if we may so call it, toward the appearance and form of other animals, there is an equally perceptible return in habit and action. The place of intel- lect seems to be supplied by instinct, and by it the behavior is apparently often governed. Thus in a recorded case, an idiot girl, having, while alone and unattended, given birth to a child, turned, with the instinct of an animal, and gnawed the umbilical cord. Commonly there is a eoiisistent imitation of the habits of some one animal, and its posture and movements will be assumed, and its habits copied even to the extent of showing a preference for whatever forms its natural food. I have read of a case where a woman lived and acted like a sheep, and ate grass; and I know of a case where a young man has all the habits, and a good deal of the appearance, of a well-conducted horse. He harnesses himself to a wagon every morning and trots about all day, switching a tail which he has fabricated out of old rope, and so great is his consistency that he never fails to shy at a wheelbarrow." * Bucknill mentions cases of lunatics (mostly imbecile) who believe themselves changed to toads, to oil-fiasks, jump and flutter like frogs and bats, making all the while a sound like these animals. Esquirol reports that in a certain con- vent the monks believed themselves to be cats, and at a * The writer takes it for granted that there are no embellishments in this account, although he has frequently seen the patient and never ob- served the last symptom, w^hich, whether it existed or not, had, it is needless to say, no bearing on the question of a reversion to the equine instinct. Huxley, Darwin, and Haeckel ought doubtless to appreciate the friendly assistance thus afforded them by Dr. Macdonald; but they will find the subject of the descent of man somewhat complicated by his theory, for it is, to say the least, difficult to believe the ancestry of the human being to have started pentadactylous, become artiodactyle (sheep, according to him), monodactyle (horse, same authority), and then penta- dactylous again! As to the negro, " Cuffy," whose feet are the strongest support of the Doctor's theory, they happen to be the seat of a symmet- rical deformity which is in a direction altogether the opposite of a simian reversion. The great toes are long and stand out at wide angles from the line of the next toes, and are /ess apposable than in the normal human foot, while they should be more so than in the latter to justify the flowery language of the quotation. The italics are the v/riter's. 2/8 INSANITY. certain hour of the day went through the performances of skipping about and caterwauling. The writer has seen patients who acted like and believed themselves to be steam engines, windmills, et ccetera, and, if we were to apph' the same argumentation running through the above extract, to these cases, we might say, it requires no great stretch of the imagination to picture his (the patient's) ancestor, in no very remote generation, as an oil-flask, as a cat in some New York back yard, as a frog in some swamp of the car- boniferous epoch, as a toad in some muddy flat of New Jersey, as a steam engine in Birmingham, as a windmill on some Netherland dyke, or, finally, as a bat flitting through the darkness of some ruined castle on the Rhine, and so on ad infinitum. The presence in idiots of gyri found in the anthropoid apes and negro (Zwickelwindung) and of muscles which in normal man are usually rudimentary or absent, are facts that lend some color to the view that in some cases idiocy may be due to an atavism. It is to be insisted on, however, that no atavism can ever imitate or reproduce the links of pro- gressive development. Just as in normal development the branchial slits, the coloboma oculi, the caudal appendage, the cloaca, the supernumerary digital rays, the thirteenth and fourteenth ribs, the Wolffian body, and the carnivora- like claws and foot-pads of the human embryo imitate cer- tain structural peculiarities of the lower creation without being exactly like them; so the cerebral and skeletal pe- culiarities of atavistic idiots resemble without accurately reproducing those of the ape. It is sometimes observed that the appearance of idiots strikingly suggests a reversion to or imitation of certain ethnic types. In some cases Caucasian idiots reproduce to a perfectly wonderful degree the Mongolian features. It is to cases of this kind that Dr. Mitchell and Dr. Fraser give the name of Kalmuck idiocy. The writer has observed the same resemblance in an imbecile murderer, and in the three dwarfed idiotic brothers who are now on exhibition in a " Museum" of this city, and whose photographs ac- company a paper on the subject, published by Hammond in his " Neurological Contributions." The thick lips, large fleshy tongue, bullet-shaped occiput, curly hair, and dark skin of the negro are found in another group, and Dr. Down, who first called attention to the ethnic types in idiocy^ THE STATES OF ARRESTED DEVELOPMENT. 279 claims that not only the Mongolian and Ethiopian but also the Malay type may be found in Caucasian idiots. It is in idiots of the "atavistic" group that we sometimes find the so-called instinctive faculties tolerably well de- veloped, in contrast with the majority of those suffering from arrested brain development. Usually, however, and contrary to the current belief, the lower faculties of the mind suffer as well as the reasoning powers, and this is in harmony with the fact, that it is not alone the higher cen- tres that suffer with defective cerebral development, but that the thalami, the cerebellum, and the cerebral isthmus of idiots are often found to be defective, or asymmetrical, or both. It is probably due to a deficient trophic innervation that idiots so frequently suffer from cataract, and it must be recollected in this connection that the morbid anatomy of idiocy and imbecility is not necessarily limited to anatomi- cal defects, but tliat progressive structural lesions may develop in the idiot's or imbecile's brain.* While the sexual function is usually in abeyance in idiots, there are cases where it has been fairly well carried on. Thus, John Rouse, the celebrated microcephalous idiot on Randall's Island, is known to have had sexual relations with low women, and to have manifested at times a strong sexual appetite; and several instances are reported where idiotic girls have been impregnated and delivered of chil- dren. f The history of the confinements of idiotic mothers illustrates very finely the erroneous nature of the popular view that the idiot is necessarily a creature of strong or perfect instincts. While idiots have been confined and have like animals lacerated the umbilical cord with their teeth — an admirable provision against haemorrhage — and evidently have done so without reflection and judgment, there are many more cases on record where both reason and instinct seemed to be altogether in abeyance. Cham- beyron, in his translation of Hoffbauer's treatise on the medical jurisprudence of insanity, relates the case of an *Thus Luys {VEncephale, Mai, 1881) has found that the cortical nerve cells in idiots undergo necrobiotic changes, and Bruckner {Archiv f. Psychiatrie, xiii. i) and Bonneville {Archives de Neurologie, i, p. 81) have found a peculiar "tuberous sclerosis" which involved the cortex in numerous patches in two cases. f Unfortunately the history of the children has not been satisfactorily traced. 28o INSANITY. idiot whom he confined, whose vocabulary was limited to the sounds " ta-ta," and who, although her pelvis was well formed and the presentation a good one, did not know enough to assist the expelling power of the uterus with her abdominal muscles; and could not be made to imitate the movements necessary, although made before her by other women. She simply fingered around her genitals in a purposeless way, and after the child was born she took no notice of it whatever. The imitative tendencies are often very strong in idiots; in imbeciles they may be utilized to make good artisans of the subjects; in idiocy they lead to destructive and tragical results owing to the utter absence of any higher intelli- gence. Thus some twelve years ago an idiotic boy in Maine killed the child of the people who cared for him, hung it up, and dressed it exactly as he had seen a sheep dressed; and another, referred to by Gall, butchered a man precisely as he had seen a hog butchered. In the lowest form of idiocy speech may be altogether absent, or limited to a few inarticulate sounds, in others a few words and short sentences may be acquired. While some idiots show no spontaneity whatever, and have to be fed like infants, others are ravenous eaters. A few exhibit explosions of furious and blind violence and morbid im- pulses. Idiots rarely reach maturity. The study of imbecility and its lesser degree, feeble-mind- edness, is of much greater practical importance to the alienist than that of idiocy. It is a popular and erroneous belief that an imbecile is one entirely void of ideation. It thus happens that imbecility is often overlooked, when the subject is in the lower walks of life, and that, as Georget very happily observes, " it is above all in the inferior walks of society, where the individuals need but little intelligence to carry out simple labors, and to fulfil limited social obli- gations, that only those are considered imbecile who are not even able to lead a horse or to watch a herd." A degree of imbecility which would scarcely be observable to the laity in a hod-carrier, would be very manifest in a school- boy and academical scholar. The writer has known imbe- ciles, who had to be removed from school because unable to keep up in their studies with children many years their juniors, to become successful mechanics and good copyists. Even in asylums there are many imbecile inmates who are THE STATES OF ARRESTED DEVELOPMENT. 28 1 employed in the garden, the kitchen, as aids in the hospital wards, and who are occasionally more methodical and re- liable in their limited sphere of action than the attendants placed over them are in theirs. The imitative tendencies which are more common here than in idiocy are often uti- lizable, as has been previously observed, in making of the imbecile not only a good, but sometimes a very skillful mechanic. His mechanical skill is mainly shown in the di- rection of imitation and reproduction, and but rarely in a new or untrodden field. It is similar with other mental processes. Imbeciles sometimes have an excellent memory for simple facts. There are instances on record where im- beciles have known the dates of the birth, marriage, and death of every person dying in a certain community for thirty years, or the time of departure of every railroad train that had left a certain station in the same time. But the imbecile is unable to form or to unravel those complex combinations of which simple impressions are the compo- nent units. The mental state of the imbecile has been very well expressed by the statement that those mental co-ordi- nations acquired in the course of a higher civilization have not been formed in him. (See page loi, foot-note.) While the imbecile is defective as to his reasoning ca- pacity, his emotional state may present every analogy to that of healthy persons, or approximate that of other forms of insanity. Thus, there are imbeciles who are mild, affec- tionate, good-natured, and even philanthi opical ; on the other hand, there are imbeciles who are treacherous, suspi- cious, and cruel. Moral defect is a prominent feature of some cases, and this condition may be the chief manifesta- tion of mental deficiency. There are subjects whose rea- soning powers are fair, whose memory is excellent, who are perhaps, accomplished in the arts, but in whom the moral sense is either deficient or entirely absent. The term moral itisa?7ity of authors should be limited to this class of sub- jects, and a much better term to use would, in the writer's opinion, be moral imbecility. Morbid projects, imperative impulses, and morbid ego- tism are found in some imbeciles, and in such cases it may be difficult to decide whether they appertain to the group of imbecility or of original monomania. There are numer- ous other points in which imbecility proper, and mono- mania, which may in some respects be considered a "par- tial imbecility," approach each other. Several of these have 282 INSANITY. been referred to in the chapter on the somatic signs of the predisposition to insanity (page 88); a most remarkable one is the fact that one-sided talent, other than that resulting from the imitative tendency referred to, is sometimes found in imbecility, just as a similar condition is found in monomania. Thus imbeciles have been known to manifest a marked aptitude for the arts, such as music. This latter has been especially noted by Meyer in imbeciles present- ing the crania progenia. The one-sided development of special faculties, and the positive signs of alienation, such as moral perversion and anomalies of character, are characteristic rather of the hered- itary than the acquired cases of imbecility.* Both imbecility and idiocy are sometimes marked by other disturbances of the nervous functions than those com- prised in the mind. Epilepsy is a frequent accompaniment, and may be very bizarre in those cases where it is the re- sult of a cerebral defect, involving a few muscles or one ex- tremity, or being associated with a choreiform aura. Both idiocy and imbecility may be dependent on early epilepsy, but more frequently the mental defect and the convulsions are collateral phenomena, both depending on defective development. Spastic symptoms, contractures, strabismus, peculiar speech defects — manifested in the inability to pronounce certain consonants — and stuttering are also noted, and it is the occasional presence of all these signs in hereditary monomania (Originare Verriicktheit) that gives additional force to the view that there is no absolute line of demarca- tion to be drawn between the various forms of the degen- erative nervous states. The course of idiocy and imbecility is usually unmarked by any changes, and these conditions are therefore, as a rule, stable ; occasionally progressive deterioration is caused by epileptic fits, and where hydrocephalus and * Krafft-Ebing makes the sweeping assertion that the one-sided de- velopment of special faculties is never found in acquired imbecility. It is more correct to speak of their presence as a characteristic feature, for exceptions undoubtedly exist ; just as there are well-established cases where acquired imbecility has chiefly manifested itself in the moral sphere, although the rule is that moral imbecility is more frequent in the transmitted forms. In the case of Louisa W e, exhibited before the N. Y. Neurological Society last December, whose imbecility developed with a scarlatina, moral perversion was the most prominent of the con- stant symptoms. An analogous case has been reported by Hughes. THE STATES OF ARRESTED DEVELOPMENT. 283 meningitis are the causes, exacerbation of tiie morbid proc- ess may lead to further impairment of the mind. In the latter cases the cerebral disorder may directly lead to a fatal termination. Unless syphilis is the cause, and rarely then, therapeutic measures are incapable of doing any good, Fig. io. -"^ r.v\-v -. - 1. •>. .-^ . r.v^•^ ■ - ^. ••'•.- • ^-Xi'i, ■.*.'.'•• • ';:•' ■■■c^ J-V-.M-V', /.'■*•■ • 'f:--„-:f:- k * '... -^ •'. k •' :- ^ •'. t and the prognosis, as far as the development of the mind is concerned, is as bad as it can well be. As to the life of the patient it is usually shortened by intercurrent diseases, to which the feeble body of the imbecile, like that of the idiot, readily succumbs ; in a few cases the bodily health may be good, and the subject reach old age. A peculiar form of idiocy is found associated with a dis- order endemic to certain mountainous districts, particularly 284 INSANITY. the Alps, Pyrenees, and Cordilleras. This is a constitu- tional deterioration manifesting itself in pronounced anom- alies of the entire physique. There is usually great physi- cal deformit}^ the head appears swollen, the features are coarse, the nose depressed at the root, the belly is distended, and the cheeks puffy owing to a hypertrophy of the skin and subcutaneous cellular tissue. With this the thyroid gland is commonly enlarged. A more disgusting object than such Fig. II. a cretin, with his childish expression, yet old-looking teat- ures, the deformed body and the enormous lobulated goi- trous appendage, cannot well be imagined. True cretin- ism has not yet been observed in North America, but a simi- lar condition has been noticed by the writer in three children of parents living in our swamps, and is probably the expression of a paludal cachexia. The mental phenomena of cretinic idiocy are like those of ordinary idiocy. Similar physical defects are found, in addition to those which are characteristic of the cretinic state itself. Thus, cretins, like idiots, are liable to epileptic convulsions, their dentition is imperfect or retarded, and THE STATES OF ARRESTED DEVELOPMENT. 285 the teeth decay early, and in extreme cases walking may be impossible. To enumerate all the interesting and significant anatomi- cal conditions, particularly of the skull and brain, found in the various forms of idiocy and imbecility, would require a special volume. In addition to those anomalies mentioned in general terms in the first part of this work, the following, found by the writer, may be briefly referred to: In two imbeciles, one of whom had a hypertrophy of the brain, that organ presenting one of the heaviest weights on record (68 ounces), there was found disproportionate thickness of the outer or barren layer (ependyma formation of Mey- FiG, 12. nert) of the cortex, over the entire expanse of the two cere- bral hemispheres. With this there was a relative sparseness of ganglionic elements in the other parts of the cortex, par- ticularly'' noticeable in the granular layers. The two accom- panying figures illustrate the difference between the normal cortex and that of the imbecile; it is a suggestive fact that one of the chief respects in which the cortical structure of man differs from that of the lower animals is in the relative reduction of the barren layer at the expense of those which are rich in ganglionic elements. In the case where the relative overgrowth of the barren layer was most marked of the two referred to, much more so than in the one from which the illustration was taken, the walls of the blood- 286 INSANITY. vessels were found to be sclerotic, and there was a general preponderance of connective tissue elements over the ner- vous structures throughout. Another condition was found by the writer which at present he is unable to offer a satisfactory explanation of. This consists in the presence, in large numbers, of nuclear bodies, surrounded by a little granular protoplasm, and contained in clear round spaces of the neuroglia (Fig. if).! I They differ from the similar bodies found in paretic demen- tia and in other organic diseases of the brain in the fact that they incorporate the finely granular protoplasm re- ferred to, which resembles that of nerve cells. The same kind of bodies are found in large numbers and in special layers in the brains of the lower mammalia, and their pres- ence in the cortex of the imbecile may indicate an arrested state of histological development. Among the anomalies in the type of the convolutions which dave been studied in so large a number of cases, the most interesting are the deformities of the occipital lobe. The latter is often shortened, or the seat of microgyria, that is, abnormal smallness of the gyri, a condition which is sometimes associated with deficiency of the splcnium of the corpus callosum, as was the case in one of the imbeciles who were examined by the writer.* In several Caucasian imbeciles pathologists have found the gyrus of the cuneus running superficially, as in the chimpanzee, and the so- called "Affenspalte" (ape-fissure) of the convex surface of the brain (Fig. 12) has been so termed because it imitates in disposition the opercular fissure of the apes. It is, how- ever, not a perfect homologue of that fissure, though its presence, when it is due to the fusion of the external oc- cipital with the internal perpendicular occipital sulcus, is a significant sign of disturbed cerebral growth. CHAPTER XXI. Monomania — Preliminary Considerations. Probably no word in the nomenclature of mental science has been so confusedly used and has led to so much mis- understanding, and consequent protest against it, as mono- * " The Etiology of Insanity," loc. cit. MONOMANIA — PRELIMINARY CONSIDERATIONS. 287 ■mania. By this term the great Esquirol, its originator, designated that form of insanity in which, while the mem- ory, the conceptions, and judgments generally are not de- stroyed, and no pronounced emotional disturbance exists, yet the patient is controlled by some expansive delusion or •ambitious project. Esquirol's failure to appreciate the fundamental feature of monomania led to his separation of the same class of lunatics, whose delusions are of a for- mally sad character, under the term lypemania (melancholia), thus placing them in the same group with the emotionally depressed patients. The untenability of this distinction must be evident when it is borne in mind that the expan- sive delusion of him who to-day believes that he is a king, may to-morrow become masked' by the depressive delusion, that he is persecuted by the usurper of his throne; or, to cite a case which may be better illustrated in American asylums, the projector of some insane invention, who, before being •committed to an institution, revels in bright anticipa- tions of the prospective income to be derived from it, after his interdiction will develop the depressive delusion, that the invention or its secret has been stolen from him, and that, to prevent the pressing of his just claims, he has been immured in an asylum on the certificates of conspiring phy- sicians. Esquirol's pupils and contemporaries recognized that so- called "partial insanity" — which term, when divested of the erroneous conceptions still clinging to it, is a fair vernacular rendering of " monomania" — not only manifests itself in dis- turbances of the conceptional sphere, but sometimes also in morbid impulses and affective perversion. Here those alien- ists who delighted in burdening the infant science of psy- chiatry with new systems of classification found a fruitful field for innovation. Whatever the direction in which a lunatic manifested his most prominent symptoms, that di- rection determined the coining of a new term ! Persons who exhibited a tendency to homicide were termed homici- dal monomaniacs; those who enjoyed thieving were classed as kleptomaniacs ; those who delighted in conflagrations were denominated pyromaniacs,* and so on, till no un- usual act committed by the insane had been left uncan- vassed. The designations " Gamomania," or " the insane * It must be stated here that some of these terms, having become as- sociated with fixed clinical conceptions, are still in use, and have ac- objects related to the patient's ideas: in simple melan- cholia, simple mania, primary confusional insanity, period- ical insanity, paretic dementia ; c. of multifarious, usually disagreeable, objects: in alcoholic insanity, epileptic insanity, paretic dementia. III. Imperative Conceptions and Impulses : a. continu- ous : in monomania, imbecility; b. periodical: in periodical insanity; c. episodical: in simple melancholia, hysterical in- sanity, paretic dementia, monomania, imbecility. IV. Abulia: in simple melancholia, prodromal period of mania and paretic dementia, alcoholic insanity, periodical melancholia, forms ending in general mental enfeeblement, monomania with overwhelming hallucinations and de- lusions. V. Hyperbulia: in maniacal phases of simple mania, paretic dementia, periodical insanity, expansive monomania. VI. Marked Emotional Disturbance : A. Without in- tellectual motive; a. angry (i) simply: in maniacal furor, pa- retic furor; (2) angry afui treacherous: in epileptic, alcoholic, and paretic furor; (3) angry and anxious: in melancholic frenzy, transitory frenzy, katatonia ; /'. expansive, good- humored, or pleasurable: in simple mania, paretic dementia, periodical mania; c. depressed, sad, or anxious: in simple melancholia, periodical melancholia, alcoholic insanity, ep- ileptic insanity, paretic dementia in early stages, katatonia, insanity of pubescence.* B. With intellectual motive; a. an- * This is also the order of the depth of the emotional disturbance. 350 INSANITY. gry and expansive: in episodical delirium of monomania; i. depressed: in prodromal period of mania, monomania with depression, primary deterioration. VII. Impaired Consciousness, of a Marked Degree and Demonstrable Kind : in epileptic insanity, transitory frenzy, stuporous insanity, melancholic frenzy, alcoholic frenzy, delirium grave, maniacal and paretic frenzy, cata- leptic phases of katatonia. VIII. Mental Weakness Prominently Developed : a. itivolving the mental faculties generally: idiocy, imbecility, pri- mary deterioration, dementia — whether terminal, epilep- tic, alcoholic, or from organic disease — delirium grave; h. with '^ focal" lacunce: paretic dementia, syphilitic dementia, chronic alcoholic insanity, secondary confusional insanity, primary confusionalinsanity, insanity of pubescence. IX. Mental Weakness extending in Limited Direc- tion : monomania. X. Marked Amnesia, aside from Unconsciousness : in epileptic insanity, delirium grave, paretic dementia, syphi- litic dementia, senile dementia, dementia from organic disease, chronic alcoholic insanity, terminal dementia, chronic confusional insanity. XI. Somatic Stigmata: in idiocy, cretinism, imbecility, monomania, epileptic insanity, periodical insanity, hyster- ical insanity, exceptionally and then non-essential in all other forms. XII. Active Disturbance of the Bodily Functions: in delirium grave, melancholia, stuporous insanity, mania, katatonia, frenzy, initial and terminal periods of paretic dementia, senile dementia, monomania with hypochondri- acal or persecutory delirium. XIII. Special Trophic Disturbances: in delirium grave, paretic dementia, syphilitic dementia, dementia from or- ganic disease, epileptic dementia, melancholia, terminal dementia. XIV. Positive Disturbances of Locomotion : in pa- retic dementia, syphilitic dementia, delirium grave, de- mentia from organic diseases, epileptic insanity, alcoholic insanity. XV. Speech Disturbances: a. acquired: in paretic de- mentia, syphilitic dementia, dementia from organic disease, alcoholic insanity; b. congenital : idiocy, imbecility, mono- mania. DIFFERENTIAL DIAGNOSIS. 35 I XVI. Tremor:* a. senile dementia, alcoholic insanity, dementia from organic disease (multiple sclerosis), paretic dementia, syphilitic dementia, epileptic insanity; b. true emotional tremor, any form with high neural excitement such as mania, frenzy, monomania with episodical deliria. XVII. Oddities of Speech: a. echolalia:\ in imbecility, in- sanity of pubescence, dementia, imbecility; b. verbigeration: in katatonia, epileptic insanity, hysterical insanity, chronic confusional insanity, insanity of pubescence; c. rhyming: in katatonia, insanity of pubescence, epileptic mental states, sometimes in any episodical excitement. XVIII. Convulsions : in epileptic insanity, paretic de- mentia, syphilitic dementia, dementia from organic disease, katatonia, an accidental accompaniment of other forms. While but the main disturbances are detailed in this schedule, the latter will serve as a guide to a provisional diagnosis at least, following the plan detailed in the two hypothetical cases detailed above (p. 342). Suppose that a history of a convulsion or convulsive movement is given in connection with mental disturbance ; it may according to the schedule be an evidence of four mental states. The most frequent form with convulsions is epileptic insanity; if now a confused delirium of a partly aggressive and depressive character (I), hallucinations of multifarious and disagree- able objects (II), angry and treacherous excitement (VI), impaired consciousness (VII), positive disturbances of loco- motion (XIV), and verbigeration (XVII) are found, the physi- cian may positively pronounce the case one of epileptic insanity. And this he may do if only a majority of the signs enumerated are present, if, as is sometimes the case, the hallucinations are agreeable, if there is no motor distur- bance and no verbigeration ; for the symptom combinations * We are not yet able to differentiate by clinical signs all the varieties of tremor encountered among the insane; the possibility of confounding the tremor due to excessive smoking with that of alcoholism should be therefore borne in mind. There are certainly some smokers whose tremor cannot be distinguished from that of paretic dementia; indeed there are reasons for supposing that nicotine may affect the central ner- vous apparatus in a similar direction. Paretic dementia has become very frequent among Austrian army officers, owing to their habit of consum- ing large quantities of what they term "Virginia segars." These are perforated by a reed, so that the smoke is not, as in the ordinary rolled weed, deprived of most of its deleterious ingredients. \ Echolalia is the thoughtless repetition of words and phrases spoken by others, the subject not associating any mental conception with them. 352 INSANITY. of the other forms associated with convulsions are alto- gether different, and do not coincide except in unimportant details wfth those of epileptic insanity. Among the evidences aiding in the differential diagnosis of the various psychoses are the age, sex, heredity, and vocation of the patient. A man at forty cannot be a pubes- cent lunatic (though he may have begun as one), nor a senile dement. A female is less likely to suffer from pa- retic dementia than a male, and a male less likely to be a periodical lunatic than a female. A patient with insane ancestors is more likely to suffer from the psychoses asso- ciated with a. neurotic taint, than one whose ancestry is free from insanity. A Wall-street speculator is more likely to be a paretic dement than a farmer. But these facts are of relatively slight value, and merely collateral to those enumerated. Where the diagnc^is of a special form of insanity cannot be made, the alienist is compelled to limit himself to the question of the existence of insanity in general. To deal with so obscure a case, all his diagnostic acumen must be employed. It is then neither hallucinations, delusions, motor disturbances, nor amnesia that lie on the surface and indicate the line of examination to be followed. He must test for pyschical weakness in the abstract, for ab- normal irritability, logical perverseness, abulia, hyperbulia, lack of reaction, and abnormal emotional states, whose characters language cannot portray, so that they can be appreciated in the living subject only. CHAPTER III. The Recognition of Simulation. The psychological diagnostician has less frequently to deal with the feigning of insanity by the sane than with the dissimulation or concealment of insanity by the insane. Persons who have once been inmates in an asylum, those who have sufficient mind to know the meaning of a medical examination, and particularly those who have an occasional glimpse of the fact that they are considered insane, or in THE RECOGNITION OF SIMULATION. 353 part recognize their insanity themselves, are frequently- very difficult to examine. For however much the alienist may become satisfied from the expressions, the manner and histories of such patients, that they are insane, they obsti- nately conceal those symptoms which it is desirable to dis- cover for the purpose of satisfying the legal, or it may be the medico-legal, demands of a commitment or an exami- nation undertaken for forensic purposes. Simulation, although far from uncommon, is not as often resorted to as some writers would like the public to believe in order to facilitate the reception of testimony "arranged " to suit the demands of public prejudice and of medico- legal conspiracies. Historical instances of simulation are cited in the various treatises on insanity, and it seems that the history of feigned mental disease is almost coeval witii the authentic history of the human species. It was known to Homer, who describes Odysseus as feigning insanity to achieve a special purpose. Solon shammed insanity in order to stimulate the Athenians before Salamis; and David is described in the Bible as feigning dementia, and resorting to the same artifices which are employed to-day by those simulating that condition. As might be antici- pated, insanity has been feigned for special and usually selfish purposes. Such nobler objects as that of Brutus, who escaped persecution and threw sand in the eyes of the Tarquins, in behalf of Rome by this means, cannot be carried out by the aid of simulation in the present state of society. To-day it is usually resorted to by criminals who have no other hope of escape from punishment than the "insanity dodge"; by persons desirous of annulling contracts which they regret having made, and which they hope to have set aside by proving mental incompetency at the time of making them; and by sensation-seeking and enterprising newspaper reporters who desire to enter asylums and to "investigate" their management.* The possibility of pro- longed simulation, as a step to the contemplated commis- sion of a crime, by a calculating criminal, must also be borne in mind. * Kiernan detected a newspaper reporter who had had himself com- mitted to the workhouse as a pauper, and there shammed insanity and secured his transfer to the City Asylum for the purpose of publishinaf the abuses which there was reason to believe were enacted there. One re- porter remained an inmate for nearly half a year at the Bloomingdale Asylum without detection, and accomplished his purpose to the fullest extent. 354 INSANITY. The subject of the simulation of insanity offers for the alienist's consideration two very distinct branches: the first is the simulation of insanity by ignorant persons; the sec- ond the simulation of insanity by persons who have had opportunities for studying or observing insanity. In the former case, detection is easy; in the latter it is more or less difficult; and there are instances on record where the best alienists have been puzzled or deceived by simulators whose skill in feigning reached the degree of the most consummate acting, and must have been based on skilful observation.* The truly wonderful power of endurance manifested by some simulators renders their exposure a far more difficult task than it is commonly supposed to be. Thus Vingtrinierf relates the case of one Picard who had been guilty of fraudulent bankruptcy and then shammed insanity for five years. The same person had previously simulated incontinence of urine for an entire year, in order to exempt himself from military service, and persisted in this, although his comrades in the barracks resorted to various and even cruel devices to check his disagreeable habit. The publicity of trials, and the full reports of ex- pert and pseudo-expert testimony given to the public in the daily papers, are adding not a little to the difficulties of the subject. Our skill in the detection of simulation is in- creasing from year to year, but the skill of the simulator is also increasing. Shortly after the Gosling and Prouse Cooper trials in New York City, a noted criminal lawyer of the lowest possible morale instructed a defrauding lawyer, who had been formerly a medical student, to feign paretic de- mentia, and so far from overdoing matters — the fault of most simulators — the latter limited himself strictly to acting the symptoms of the prodromal period of that disorder to the best of his ability. It was at one time, and is still with some, a commonly received test that the simulator does not repudiate the idea of being insane, which the truly insane person does. Aside from the fact that the insane do sometimes recog- nize their insanity and exceptionally admit it,f which * Ollivier. Jacquemin, Ferrus and Marc were thus completely deceived bv the simulating murderer Gilbert, and even Esquirol at one time sus- pected him to be insane. To-day, however, the writer believes, the shamming of such a person would not have proven as successful. + Ann. d'hygiene publique et de medecine legale, 1853. t Seventeen patients, suffering from well-marked forms of insanity, in. THE RECOGNITION OF SIMULATION. 355 alone should have forbidden the adoption of so faulty a criterion, it is to-day valueless because many simula- tors know or believe it is considered such a test, and af- fect to disclaim the existence of the malady which they wish to have imputed to them.* That they overdo this, as well as other manufactured symptoms of derangement, is but consistent with the general character of the simu- lator. Derozier, whose interesting case is cited from Morel by Laurent — after such simulator-like answers as "245 francs, 35 centimes, 124 carriages to carry it," in re- sponse to the question, what his age was — being asked " Has your head been long out of order?" replied, " Cats, always cats ..... I am not insane, the insane don't turn around "; he then arose and turned around three or four times, as if to give his own assertion the lie. Usually the physician's attention is directed to the possi- bility of the existence of simulation by some inconsistency in the clinical picture, exhibited or feigned by the subject examined. Such clearly marked affections as those detailed in the second part of this work are very difficult to feign correctly in every feature, and it is a task requiring consum- mate art for a simulator to remain within the true patho- logical boundary-line, and not to break through it in the di- rection of caricature. But there are some obscure and mixed groups, insufficiently studied, and for that reason not well recognized, in which a simulator may succeed in finding a place, he imposing his symptoms on the physician as signs of a mixed or impure form of insanity. An important step in the determination of the existence or non-existence of simulation is the investigation of the previous character of the subject and the existence of a motive for simulation. A cunning knave, whose history is a repetition of crimes, is more apt to have had the idea of eluding paretic dements, periodical lunatics, suicidal melancholiacs, one hallucinatory monomaniac, and one patient suffering from traumatic insanity with multitudinous hallucinations and violent impulses, con- sulted the writer at his office for their insanity. This enumeration does not include subjects suffering from incipient signs of paretic dementia, primary deterioration, alcoholic insanity, melancholia 2sv^ folie du doute, whose number is far greater. * This was the case with a business man who had been ruined by op- erations in Wall Street, had written numerous insane letters of a threat- ening character to a leading operator in the same line of business, and was subsequently discovered to be the author and indicted for attempt at blackmailing. 356 INSANITY. simulation suggested to liim, and to have received instruc- tion in the art of simulation, than a straightforward per- son of previously honorable character, or who has com- mitted his first offence. A murderer, ravisher or abductor is more likely to sham insanity than a thief, because the former's risks of suffering the death penalty or of being long confined in jail are much more serious than the prospect of an asylum sojourn of at most a few years, while in the lat- ter case the comparison of a sojourn in jail with the remain- ing in an asylum, involving as the latter does the neces- sity of continuing simulation day and night, is very apt to result in a choice of the prison as the lesser evil. In coun- tries where the discharge from asylums is easily obtained and prison discipline is rigorous, prisoners sometimes feign in- sanity with the object of securing a change of quarters. The idea that the mere fact that a prisoner presenting signs of mental derangement is more likely to be a simulator than a real lunatic, and that simulation is frequent in jails, is, how- ever, an erroneous one. The French and German statistics conclusively prove that simulation of insanity is rare among prisoners, and not at all frequent among criminals in gen- eral.* On the contrary, real insanity is of comparatively frequent occurrence in jails, and much more common in prisoners than in the ordinary population, for there are special moral causes, remorse, isolation, vexation and de- spair, which, added to the physical stagnation and depriva- tion of prisoners, combine to break down their mental health. Prisoners of war and recruits resort to simulation more frequently than any other classes. The melancholy case is related of two French prisoners of war who feigned insan- ity for a long period, with the intent of escaping by this means, and with such success that both ultimately became really insane. Most simulators who are convicted of simu- lation admit the distressing effects of the constant strain and effort on their nervous functions, and the warning that feigned insanity may become a real and incurable disordei" should be conspicuously written in every prison corridor. * The opposite idea, entertained and diligently disseminated among the public on the occasions when " popular" testimony can be safely given, finds its expression in the writings of an asylum physician — it would be unfair to say an alienist — who pronounced at least two murderers sane and shamming (one of them without any personal examination), in both of whom gross and extensive disease of the brain was iound />ost mortem. THE RECOGNITION OF SIMULATION. 357 It is known of other feigned disorders, such as epilepsy and traumatic tremor, that they may, if persisted in, develop into the real affections, and the analogous causation of actual insanity by simulation is no more problematical and just as plausible as that of the nervous disorders men- tioned. Very strange motives are occasionally observed to under- lie simulation. Laurent speaks of former asylum patients who, after their discharge as recovered, shammed insanity to get back to their old quarters. A still more remarkable^ case is that of a young girl who feigned insanity in order to keep her sister — who was actually insane — company. The simulation of insanity by the insane sometimes fur- nishes more troublesome problems to the diagnostician than that of the sane. This remarkable combination of real and feigned disease is by no means rare. The writer has not seen a single insane criminal who was not aware to some extent of the immunity to punishment which the insane enjoy, and who might not — as was the case with some — have feigned mental disturbance.* The mur- derer Dubourque, who was undoubtedly insane, feigned amnesia of his crime, and was convicted of the feint. An * Guiteau has been erroneously supposed to have been a simulator. From the time he fired the fatal shot on the President to the moment when the drop of the gallows fell, there was not a moment in his career, not a word said or a deed done by him that supported this idea. If ever a more consistent record of the insane manner, insane behavior, and in- sane language has been made anywhere else in the history of forensic psychology than in the Guiteau trial, the writer does not know of it. Guiteau put in the plea of transitory mental disturbance, claiming Abrahamic inspiration. This is no more surprising than that an insane lawyer, whose practice had always been in devious channels, should, with the idea, under which the prisoner labored, of being his own counsel, use every means to escape an impending fate and carry out his " mission." Guiteau was unaware of the existence of his real insanity, repudiated it consistently, felt deeply insulted by that true opinion which wounded his self-love, and did everything in his power to fix the noose around his neck by combating it, showing off his apparent "smartness," and insulting his counsel. At no time did he make the slightest pretence of being or of having been really insane, or give himself the appearance of insanity, but, consistently with his egotism, he placed himself side by side with Abraham acting under an inspiration, as he claimed to be the silent partner in the firm of "Jesus Christ & Co." It is an indelible blot on American psychiatry, a blot for which our real alienists are not responsible, but which has been made by a combination of medical poli- ticians, gynaecologists and laymen, that in the case of Guiteau these and other of the strongest evidences of insanity were marshalled into line as evidences of the very opposite condition. 358 INSANITY. imbecile and epileptic pickpocket with marked somatic signs of constitutional defect, feigned religious derange- ment, and succeeded in obtaining a change of locality from the penitentiary to the asylum. Whenever the physicians came into the ward he dropped down on his knees in an attitude of profound religious meditation, but at no other time. An imbecile murderer who presented the type of Kalmuck idiocy w^hen arraigned for trial, knowing that his defence was to be insanity, tied a cloth around his head and buried the latter in his hands, associating the vague idea of assisting his counsel and the medical witnesses ap- pearing in his behalf with the supposed necessity of giving the appearance of having a headache. Nichols, of Bloom- ingdale, according to Kiernan,* observed a case of simulation of dementia under the advice of lawyers, by a delusional lunatic, who had committed murder in obedience to the command of the Virgin Mary, appearing to him in the flame of a candle. Both the feigned and the real insanity were detected, and the latter was unmistakable throughout the patient's asylum sojourn. While a number of observa- tions of similar complicated cases have been collected in Europe by Laehr, Stark, Delasiauve, Ingels, and Pelman — ■ the last mentioned being led to express the extreme and erroneous view that all simulators are mentally abnor- mal, Hughes was the first on this side of the Atlantic to direct attention to this subject. This authority says : " The insane appear at times, when they have an object to accomplish, more crazy than, and different from what they really are ; this is the sense in which we use the term simu- lation, and this condition is akin to that of feigning by the sane. Simulation, while it presupposes a degree of san- ity,! does not require that the patient should be wholly sound in mind, and it might be attempted by a convales- cent patient not thoroughly recovered, or desirous of re- maining longer in the hospital, or for some other cause." That this does occur is supported by several cases ob- served by the author cited, and by another referred to in thefirst part of this volume (page 34). There is not a single case on record in which a lunatic who simulated in- sanity recognized his real disorder. *" Simulation of Insanity by the Insane." Alienist ami Neurologist, April, 18S2. fit would be more correct to say " intelligence" than "sanity." THE RECOGNITION OF SIMULATION. 359 The popular idea of insanity, which is responsible for its frequent non-recognition by juries, judges, and some phy- sicians, is also the cause for the ignorant simulator's failure. His belief is that the insane are either stark raving mad and incoherent at all times and on all points, or that they must be in a condition of fatuity. If he has read novels, he will model his insanity after that of some romancer who possibly has never seen a lunatic, and of course make as melancholy a failure as in any other event. There are five conditions in which gross incoherence is found com- bined with excitement — furor, frenzy, transitory insanity, febrile delirium and acute confusional insanity. We know that furor and frenzy, whether in the maniac, melancholiac or paretic, must have been preceded by a history of other mental signs, which it is difficult and in fact impossible to imitate ; we know that transitory insanity is rare, of brief duration, and coupled with amnesia, and that the patient pays no rational regard to his surroundings during the at- tack.* Febrile delirium is associated with somatic phe- nomena which a simulator could not even approach imi- tating. The feigning of acute confusional insanity alone presents any chances of success, on account of the unessen- tial character of the physical phenomena, the greater ease of imitating the incoherence of this disorder, and the ab- sence of that deep emotional condition which the simu- lator of mania and melancholia usually fails to take into account. But even here, as elsewhere, the delirium of the simulator has specific characters. Real raving ma- niacs, if utterly incoherent, show the expression and so- matic signs of their condition ; in milder raving there is some connection of the thought with the surroundings; in simulated raving there is usually none. If a confusional or mildly maniacal patient stops to answer a question, which he usually does, he answers it with some degree of respon- siveness. If asked his age, he will answer reasonably or err a little but never absurdly. He may assign a very great age, or a very much lower age than his real one, ac- cording as his tendencies are in the direction of megalo- mania or of micromania, but he will never say, as Derozier did: "245 francs, 35 centimes, 124 carriages, to carry them away." These incoherent phrases might have come *Schwartzer, "Die transitorische Tobsucht" relates a case of simu- lated transitory frenzy. 360 INSANITY. from a confusional lunatic, but not as answers to such a question : there is too much method in madness to permit of such absurdities ! As a rule, the simulator in those quiet periods of his artificial excitement which are the expression of inability to keep up the exacting effort of simulation, does not recognize his friends, his surroundings, or recollect any- thing that occurred about that period of time which he has a motive to make people believe he was irresponsible in. The true maniac, however, happens to be lucid in those very periods, recollects his family and his friends perfectly well, and if he has committed a crime, while he may be acute enough to desire to conceal his recollection of it, he will not, if the examination is led up to the period of its commission, gradually claim to forget real circumstances occurring be- fore and after it, as the simulator, who is always on his guard, does. It is only in epileptic mania and in paretic dementia that such amnesia really occurs; but here the physical signs or the history, or both, present us with un- mistakable signs of these affections if they really exist. The simulator also errs generally in allowing his feigned disorder to explode as well as to recede too rapidly. As a rule the psychoses develop gradually: those that do not, have certain characteristic features unknown to simulators. Thus transitory frenzy is characterized by a noticeable impair- ment of consciousness, and epileptic mania by the peculiar physical appearance and condition as well as the history of the patient. Outbreaks of furor in paretic dementia may occur quite suddenly in a remission or in the prodromal period when the patient is not supposed to have been insane by the laity; but the distinguishing marks of this furor and the accompanying physical signs are too numerous and the residual state too characteristic to be ever confounded with simulation by the expert. Sudden recovery is also suspicious, but not as much so as a sudden incubation of the malady. Mania has been known to disappear by a crisis, and men- strual insanity in exceptional instances gives way almost like a flash while the disorder is apparently at its height. Another characteristic feature with many simulators is the intensification of their symptoms when under examina- tion. A simulator will become more incoherent or de- mented and excited or obtrusive with all his symptoms when the physician approaches, than at any other times, for he has a motive in bringing his symptoms to notice. Some- THE RECOGNITION OF SIMULATION. 361 times the approach of the physician or of any one else will irritate real lunatics, but not beyond the limits of a diseased condition which is as recognizable in the interim as in the explosion. Then, too, if the mental capacity of the simu- lator is questioned in his presence he will do all in his power to strengthen the physician in what he sup]:)oses to be the latter's belief, while the real lunatic, unless sunken in abject dementia, will try to show a mental capacity which he has not, and to appear better than he is ; this attempt, as so old an author as Hoffbauer knew, only makes the real lunatic appear the more deprived of reason.* That author refers to the case of a melancho- liac who having a relapse of his melancholia, did the most extravagant things not natural to his illness in order that the relapse should not be expected to have occurred. It is in the nature of the case that the real lunatic suffering from those forms of insanity from which the simulator is most like- ly to select his model when he tries to appear sane, not being able to appreciate and to assume the sane character should show his mental infirmity only the more prominently. The simulator, on the other hand, not being able to appreciate or to assume the insane character, reveals the sham charac- ter of his malady the more he rants and acts the madman. The simulator also labors under the mistaken impres- sion f that the insane do not reason. It so happens that too great a degree of incoherence in a delusion justifies the alienist in suspecting its genuineness. To that kind of delusions which the simulator undertakes to imitate, the statement that there is method in madness preeminently applies. The simulator makes the common mistake of be- lieving that insanity is a chaos of symptoms, although even as a morbid condition it has laws of its own. Persons who feign a quiet form of insanity usually at- tempt to imitate dementia. A good case of the failure of this form of simulation is one detailed by Snell, of a widow who tried to have a contract set aside, and induced her children to claim that she had been and was insane. Being asked how many fingers she had on her hand, she said four. Being asked to count them, she skipped one finger, and said, "One, two, four, six." She further said that two and * Applies to the forms of insanity which are most likely to be feigned, and not to monomania, hypomania and nielancholia sine delirio. \ Shared by several of the prosecuting experts in the Guiteau trial. 362 • INSANITY. two equalled six, that she had nine children instead of seven, that her husband was dead ten years instead of five, that he died after an illness of over a week, when in reality he had died suddenly from an accident; , gave the wrong name to a child, did not know the number of the year, nor where she lived, though previously she had admitted own- ing the very house in which the examination occurred; and when asked the ten commandments, said in reply to ques- tions as to which were the first four: " ist. I am the Lord thy God. 2d. I am the Lord thy God. 3d. I don't know. 4th. Thou shalt not honor thy father and thy mother." The tendency to absurd contradiction, the feint of forget- ting so important an occurrence as the mode of death of her husband, and of simple things, in their combination as above shown, settled the fact that the woman simulated. Even imbeciles have some ideas within their limited range, and adhere to them with a certain degree of consistency which the simulator rarely shows, and as far as their basis goes they reason with a show of logic. If a dement, not absolutely in a state of fatuity, reasons badly, there is al- ways found confusion of words, while occasional glimpses of a clearer ideation struggle through ; the incoherence seems to be due to a digression from subject to subject, the main one losing its grasp on the enfeebled attention and memory. The simulator of imbecility or dementia, how- ever, either talks more confusedly than harmonizes with the thread of reasoning he unwarily exhibits, or he talks less confusedly than he should in the utter absence of a connecting bond in his thoughts ; in short, he does not balance the defects in ideation and in their expression properly. The idea has gained ground that the insane who have amnesia in fit-like spells, as in epilepsy, alcoholic insanity, and paretic dementia, never admit its occurrence, while the simulator is very ready with the words, " I don't remember." This is true in the majority of cases, but does not apply to the early phases of paretic dementia and alcoholic insanity. On the other hand, it must be recollected that maniacs and melancholiacs will in their convalescence often attempt to cut short inquiries as to their reminiscences, by the claim of amnesia. However, there is no likelihood of confound- ing these conditions with simulation of amnesia by the mentally healthy, for when amnesia is honestly claimed, and the mental condition immediately preceding and im- THE RECOGNITION OF SIMULATION. 363 mediately following the alleged amnesia carefully examined, something distinctively pathological will always be found. The absence of insomnia and impaired digestion in the acute psychosis is exceptional in real insanity, and is, to that extent, a ground for suspicion. These and other dis- turbances of the bodily functions are not, however, char- acteristic or essential features of chronic insanity,* al- though it supports the idea that a subject is really insane when the skin is in a bad condition, dry and yellow, or moist and clammy, when there is an effluvium, when the appetite is poor, the tongue coated, and the bowels are constipated. But the physician who needs these signs to convince him of the existence of insanity, and who would elevate them to the dignity of proofs of that condition, may take his place side by side with those who attempt to ele- vate the ophthalmoscope into a test of insanity for medico- legal purposes ; he has not advanced much beyond the position of Rush, who thought that he could distinguish real from feigned insanity by means of the pulse. This claim could well be made in the earlier part of this cen- tury; only a novice would rely on or propose such tests to- day. The simulator's task is rendered difficult whenever he is kept under continuous observation. The best actor may fail to adhere to his assumed character for days and nights in succession, and the necessity of being continually on his guard gives the performance the appearance of being la- bored. There are, however, instances recorded where the first period of simulation having been passed, it became a sort of second nature, and assumed an appearance of genuineness which has, as stated, imposed on the foremost authorities in psychiatry. The transfer of such subjects to an asylum is usually followed by a cure of the insanity, suspicious on account of its rapidity and its taking place in what was made to imitate an incurable form of mental disorder. It is in such cases that real insanity sometimes rewards the * The condition of the skin was the chief criterion on the strength of which an "expert" witness for the prosecution in the Guiteau trial pro- nounced him a simulator. Unfortunately, the skin of Guiteau, though it revealed no form of insanity, was m a far worse condition than that of two thirds of the insane in the institutions for the insane, to which the witness in question bore the relation of a "consulting physician" at the time of the trial. Psychiatry is not destined to become a branch of Der- matology. 364 INSANITY. simulator's efforts.* A ver}' important point to discover in the antecedent history of a suspected simulator is whether he has ever had an opportunity of observing the insane, or has read treatises on the subject. The devices for exposing simulation are numerous. Zacchias, in consonance with the spirit of his age, recom- mended flagellation; and Campagne, the douche. Both were as wrong in believing that the confession of having played a part or of having attempted deceit under these cir- cumstances has any value, as the mediaeval jurists were wrong in believing that the truth could be discovered by means of xht peine fort ct diir. The insane may be made to recant their delusions, to conceal them, or, as Leuret claimed, even to lose them under powerful motives, and it would lead to gross mistakes to adopt any vigorous measures with them. The torture of being continually watched, and of having to keep up an unnatural effort under surveillance, are far more effective weapons for use against simulation, and the clinical observation of the really insane furnishes a countless number of devices by which the pretender can be exposed, without involving the risk of being inhuman to a genuine lunatic suspected of simulation. Among the special signs which justify the suspicion of simulation are the following: ist. The subject on the phy- sician's entry may avoid looking at him and glance up at the wall, and on the physician's changing his place will look .elsewhere, demonstrativeh' avoiding looking him in the face. This is never the case in stuporous insanity, melan- cholia, katatonia, nor in apathetic dementia, the forms which a subject presenting these signs attempts to imitate. 2d. The simulator will give extravagantly absurd answers to simple questions, after the fashion of children in play when attempting to excel in saying impossible things; this is in agreement with the popular idea of insanity. Derozier being asked in June what month it was, said January, then looking out of the window, said, " Stop, one would say that it is warm." This alone sufficed to expose the sham. 3d. The simulator may take a long time to answer questions, * Jacobi (the alienist of Germany), in conjunction with Richarz, Hertz, Bocker, and Snell, pronounced a subject to be a simulator, and these eminent authorities were undoubtedly right when they did so. The first mentioned, however, on receiving this person some years after as a real lunatic in his asylum, suspected that they had all been wrong in their first opinion. This does not at all follow. THE RECOGNITION OF SIMULATION. 365 and hesitate in his answers. Delay in answering and drawl- ing are found in depressed states, but here the appearance and expression harmonize with the exhibition of thought and speech, while the simulator's expression betrays an in- telligence which his words are intended to mask. 4th. The simulator when he supposes himself unwatched will make furtive glances to see whether any one approaches who necessitates his being on guard. 5th. A person feigning epileptic and somnambulistic states may recollect per- fectly his feigned acts and expressions, and carry them into his (/ uasi Ivicid period. This never occurs in the real affec- tions. 6th. Rhythmical movements are made by some simulators which have no analogy in insanit)% or are out of harmony with the form of mental disturbance assumed. 7th. Simulators complain much more about odd and pain- ful sensations in the head than the insane usually do. 8th. A clumsy simulator may say: " I have the delusion that I am lost, that the devil is after me," or, " I have hallucina- tions of faces and voices at night." Such a person can be readily exposed to be a deceiver on other grounds, but the feature here mentioned alone suggests simulation. A true lunatic may admit that he has hallucinations and delusions, using those words, especially when examined for the pur- pose of being committed to an asylum, but when he does so he affects to admit that he" imagined those things," but never does a real lunatic at the time he has these symptoms give them names which show that he recognizes their ab- normal nature. He is lost, he is pursued by the devil, he Aears voices and he sees faces. 9th. It is suspicions if in- sanity appears immediately after a crime, or after the arrest or sentencing of a criminal, while its previous existence can be disproved. The likelihood of simulation being combined with sanity is very much diminished in case the person has already been insane, and particularly if there are somatic signs of heredity or a history of insanity in the blood relations of the sus- pected simulator. If such a person feigns, the possibility of real insanity underlying the feint, must not be for- gotten. The devices which may be legitimately resorted to, to expose simulation are the following: ist. When examin- ing the patient, let the interlocutor remark in an undertone to a bystander, that if such and such a sign were present he would know in which ward to put him, or under which 366 INSANITY. form of insanity to classify the subject. This is far safer than the suggestion adopted from the French writers by Ray, and copied from liim by some recent pamphletists, of saying tliat if such and such a sign were present, tlie inter- locutor would believe the man to be insane. This would put a cunning simulator on his guard. The writer had to deal with such a one in the case of a child abductor who had feigned insanity in a jail once before. Suspecting that the recom- mendation of the older writers would have failed, the writer turned to a bystander and said: " This is a most interesting case, and I have frequently remarked that these patients do not remember what city they are from." The criminal had previously assigned Baltimore as his home, and this was, according to the legal papers in the case, correct; but on being interrogated again, he said in a hesitating and whining voice, altogether unnatural to a person suffer- ing from monomania with sexual perversion (the form claimed to exist), " Concord, Cincinnati." 2d. While be- ing examined as to his general sensibility, the simulator may believe that anaesthesia is a desirable part of the clinical picture; he will wince when probed with a pin unexpectedly, but remain immobile when pricked after be- ing warned. This is, however, a sign which is not constant nor of great value under an}'- circumstances, though it may serve as a good basis for an accusation of shamming, made to test the moral effect of the charge on the simulator. 3d. When a simulator is accused of shamming he may either turn away from the examiner, or suddenly lapse into stupor, or undergo some other unnatural change of his symptoms. A real lunatic will either act like a sane person under these circumstances, or, as in apathetic states, show no change whatever.* 4th. A simulator if transferred from * A writer whose inspiration may be found in Blandford's chapter on feigned insanity, the ideas of the latter being closely followed with no other change than one of language, and whose article opens with the statement that " moral" and "feigned insanity" are convertible terms, says that " if you will accuse the simulator of shamming, he will scarcely fail to change his countenance." Now if that writer had ever tried the experi- ment on his own patients, he would have found that the few who had some relics of their old pride left would certainly undergo a change of countenance if accused of humbugging. Such a proposed test of simula- tion reveals the lack of any searching and fair study of insanity in some of our asylums. With the approach of insanity, particularly of certain forms, a person does not lose all the feelings of the normal human being, and equally with a sane person might resent what he may subjectively THE RECOGNITION OF SIMULATION. 367 one ward to another of an asylum, will imitate the different forms of insanity he sees there. He may appear melan- choly or demented one week, hilarious and destructive the next, and cases have been observed where simulators on being placed in the filthy ward of an asylum, with the idea that its disgusting and frightful scenes would induce them to abandon simulation — which sometimes is the case — de- voured their own excrement, acting to the best of their ability as the other inmates did. Imitation may occur in real insanity, but it is limited to delusive conceptions which are accepted by weak-minded lunatics from more intelli- gent ones, in what the French caW foiie coiiiniu/iique a.-nd folie a deux. A simulator whose signs indicate, say, dementia, monomania, melancholia, or mania, on being placed in a ward with paretic dements or epileptics, allowing him to overhear the statement that he must be either a paretic de- ment or an epileptic, and that he cannot possibly belong to any other form of insanity, will have delusions of grandeur and paralysis in the former and convulsions in the latter ward. Numerous suggestions may be made of symptoms out of harmony with the assumed mental dis- order, and their adoption serves to expose the fraud. Thus the writer suggested ptyalism in a simulated monomania, and oscillatory movements of the head in simulated sui- cidal -iaaaataajiia, with this result. It may be feasible to relate cases in the hearing of well-posted simulators, where the insane had miraculous beliefs, or spouted poetry all day, and thus to prompt the adoption of inconsistent and convicting symptoms. Of the various tests thus far enumerated, the device of charging simulation point blank should not be made until all other means have been exhausted. The simulator should not know that he is suspected until the last mo- ment. Various medicinal tests have been suggested for the pur- pose of exposing simulation, but they are of no value ; perhaps the best is ether, but comparative lucidity may occur after its use in the really insane, and both in sane and in insane persons false assertions, self-accusations, and accusations against others are made in ether and chloro- regard as a deliberate insult. This ignorance is heir to the same feeling which fifty years ago treated the insane as wild beasts, and to-day treats them like paupers and jail-birds. 368 INSANITY. form narcosis. The application of the faradic wire brush may expose a simulator, and this test is a legitimate one, because it is one of the therapeutical appliances indicated in the treatment of those stuporous and atonic states which are most likely to be imitated by those simulators with whom the device may prove successful. In analyzing simulation, as in studying insanity, the in- dividual as a whole, his surroundings, his crime, and his present mental state must be taken into account. He who really has the acquired forms of insanity must at some time have undergone a change of character; he who suffers from a congenital or inherited form must have exhibited mental defect or disturbance long before, present somatic stigmata, or have an hereditar}' history or a neurotic taint. The crime, its motive, manner of commission, and the behavior after the crime, are important elements in the diagnosis between simulation and insanity in criminals. There are some crimes which alone suggest insanity, in others the motive and the manner of commission demonstrate its ex- istence.* It is incorrect to conclude that because the commission of a crime involves deliberation, premeditation, and skill, that it cannot be the deed of a lunatic. The insane, as has been repeatedly urged by the highest authorities, and as explained elsewhere in these pages, may reason very elabo- rately from false premises.f The simulator in cases where his crime was performed with skill and careful preparation, betrays his feint by claiming complete amnesia, or saying that he must have lost his head, by showing a desire to appear feeble-minded and of weak memory, by representing his family to have been insane, or by forcing spurious insane documents on the attention of the observer. In short, the false picture of insanity is usually a caricature, and violates the laws of insanity at almost every step taken by the simu- lator, and in more than one direction, in the majority of instances. * The popular idea that the lunatic always slays openly is, however, grossly erroneous; it has been adopted as a test of real insanity as dis- tinguished from simulation, and by a curious coincidence, by the very medical witnesses who pronounced Guiteau a pretender. f The possibility of a lunatic's committing a crime from the ordinary criminal motives cannot be denied, for, contrary to the statements of those who aided in the execution of an assassin within the memory of the readers of this work, insanity does not improve the morals. THE SOMATIC ETIOLOGY OF INSANITY. 369 CHAPTER IV. The Somatic Etiology of Insanity. Having examined his patient and made his diagnosis, the physician's duty, before proposing remedial or other measures in case of insanity, is to inquire into its causation, as the proper therapeusis is often guided by a correct etiological assignment. Naturally his attention is first directed to possible somatic causes, as when remediable they are far more readily and rapidly remediable than the mental causes. Nearly all the known exciting causes of insanity are in the nature of somatic, emotional or intellectual accidents, to which the sane population is almost as much liable as the insane. The reason why insanity results in one case and not in another, must therefore with certain exceptions be sought for in some vice of the constitution — in other words, in a predisposition to insanity. That this predis- position may be acquired through traumatism, syphilis, alcoholism and other narcotic abuses we have already learned; but the most important predisposing cause of in- sanity is undoubtedly that hereditary transmission of structural and physiological defects of the central nervous apparatus discussed in the first part of this work (page 81). As far as the treatment of the hereditary transmission of the defects, on which as a basis insanity may develop, is concerned, it can only be prophylactic. And it is left for a higher civilization than ours, one in which State Medicine will no longer limit itself to the quarantining of those diseases which produce popular panics, but take cogni- zance also of those which are more insidious and equally if not more destructive or damaging to the race, to deal with the great problem of adopting rational principles of natural and sexual selection in the propagation of our species. To-day the practical alienist while regarding heredity as the most prominent subject of inquiry in regard to the etiology of insanity, is compelled to limit himself to the study of the acquired predisposition and exciting causes as the factors to be considered in prophylaxis and treat- ment. As far as the hereditary predisposition is concerned 370 INSANITY. his advice will be rarely sought; and when sought, his advice will in the majority of cases be limited to the recommendation of educational methods adapted to the case, and calculated to divert the predisposed mind into channels which shall conduct it further and further away from its threatening goal. There can be little doubt that whether an inherited disposition exists or not, that faulty educational systems, particularly when associated with the hot-house growing plan, may be responsible for serious injuries to the nervous system which may in turn pave the way for the development of insanity.* Among the physical causes of insanity, head injuries, insolation, meningitis and gross organic disease of the brain deserve the first consideration, because their in- fluence is directly and often tangibly applied to the organ of the mind or its protective capsule. Injuries of the skull affect the mind in a number of ways, and while those complicated by fracture with depression, are more likely to lead to serious mental results than simple concussion, yet even simple concussion may pro- duce chronic incurable insanity or the disposition to it, as a number of well-observed cases attest. Sometimes insanit}'^ is produced directly after an injury of this kind. Of this character are the delirium, the hallu- cinations and excitement often found intercurrent with the sopor and coma following shock, and whose prognosis is comparatively favorable. Sometimes serious lacunae of the memory are noted, and the patient may lose the mem- ory of a long period of Ms life altogether, either to regain it, or to pass into a condition very similar to primary mental deterioration. The most serious psychoses resulting from traumatism are developed months and years after the injury. Some- times they assume the character of paretic dementia (p. 201), but as a rule this is not of the pure type, and is apt in the prodromal period to be marked by the furious outbreaks and murderous impulses characteristic of what might be called the traumatic neurosis. There is a condition which might be properly called traumatic insanity^ because it does * The same applies to the feeding of the mind on morbid fiction, not at all a distinguishing characteristic of the present age by any means, though now cultivated at an earlier period of life, and consequently doing proportionately greater damage. THE SOMATIC ETIOLOGY OF INSANITY. 37 1 not accurately correspond to the ordinary psychosis, has distinct clinical characters, and is always when found, refer- rable to traumatism or to analogous causes; it develops on the basis of the "traumatic neurosis," just as alcoholic and epileptic insanity develop on the basis of the alcoholic and epileptic neuroses. The subjects of this disorder are noted to undergo a change of character, to exhibit a ten- dency to alcoholic excesses, to become morally perverse, suspicious, brutal and quarrelsome, and to manifest mur- derous or other violent impulses, occasionally associated with fits of maniacal self-exaltation or furor, usually of short duration. This condition is remarkable for its long duration and its frequent and sudden changes, the occasional lucidity of the patients being accompanied at the time by hypochondriasis. As a rule progressive deterioration sets in, and dementia terminates the history of the case. The diagnosis of this condition is facilitated by the pres- ence of certain physical signs. Tinnitus aurium, photopsia scintillation before the eyes, headache of a pulsatory or grinding character, vertigo, paresis of various muscular groups, particularly of the eye-ball, without fibrillary tre- mor, anaesthesias and hyperaesthesias, as well as insomnia, are frequent accompaniments, and some of these enumer- ated signs are present in every case. Insolation and the influence of radiant heat produce a form of insanity very much like that due to traumatism, but in the writer's experience these causes lead far more frequently to paretic dementia than the latter. Firemen on transatlantic steamers and waiters in hotels detailed to duty in the " plate-warming" room, furnish a comparatively large quota to that part of the asylum population suffering from paretic dementia in New York. The influence of meningitis on mental life is well illus- trated in the psychical disturbances, such as delirium, hallu- cinations, depression, stupor, and destructive impulses sometimes observed in the course of tuberculous and simple meningitis.* Meynert believes that abortive or * In a patient dying with symptoms of paretic dementia of a stupidly delirious type, whose earlier history was unknown — a fact that may be appreciated when it is known that he was entered in the asylum records as John Doe — chronic leptomeningitis traceable to a suppurative process in the tympanic cavity was found post-mortem by the writer. The motor signs had in this case been well marked and characteristic of the disorder diagnosticated. 372 INSANITY. self-limiting meningitis in childhood may leave behind a weakness of the mental organ, which may manifest itself in imbecility with hallucinations and delusions usually accompanied by epileptiform symptoms. According to that writer, a prolongation of the posterior cornu of the lateral ventricle beyond the normal length is found in in- sane subjects who have suffered from slight hydrocephalic troubles with or without convulsions in infancy, and the white substance in the neighborhood of the v6ntricle often contains sclerotic patches in that event. It is scarcely necessary in a work of this character to de- tail the various cerebral diseases which are occasionally the causes of insanity. The general statement may be made that genuine derangement of the mental faculties is more likely to occur with multilocular or diffuse than with unilocular or circumscribed lesions, with bilateral than with unilateral disease, with large than with small foci, with rapidly developed than with slowly developed disturbances, with hemispheral than with axial affections, and with mor- bid changes established at an early period of life than with those affecting the brain after the maturation of the mental mechanism. Next to the organic affections of the brain and its en- velopes it is the neuroses which are the expression of an impalpable brain disturbance that hold an important place in the causation of insanity. This influence has been dis- cussed in connection with the clinical description of several forms of insanity in the second part of this volume (Chap- ters XVII. and XVIII.). It remains for us to speak here of the influence of chorea in the causation of insanity. In mild cases of chorea the mind is no more seriously affected than in any other affection annoying to children, and associated with insomnia. Even in severe cases the mental faculties may be found to be quite intact,* and such disturbance as is found in the majority of cases is the result of the motor disturbance and of the ensuing restlessness, irrita- bility and peevishness of the child. In protracted cases of chorea, the mind suffers in the direction of actual insanity; in that case maniacal outbreaks, confused delirium, enfee- blement of the memory, rapid emotional change, and in ex- * The sensational claim was made at a discussion of the subject at the New York Neurological Society, that all choreic children are morally imbecile! THE SOMATIC ETIOLOGY OF INSANITY. 373 treme cases dementia may ensue. It is a psychosis with these symptoms which is designated choreic insanity. This dis- order must not be confounded with another whose title has a similar sound, namely, choreomania. The latter term was given to the epidemic impulse to dance which spread so extensively in middle Europe on several occasions in con- nection with religious movements, and which according to Yandell has occurred on the occasion of a revival move- ment in Kentucky early in this century. Fevers exert an important influence in the production of insanity. The term post-febrile insanity is given to dis- orders which complicate the crisis, or what would ordinarily be the convalescent period, of certain acute febrile processes, such as scarlatina, small-pox, typhus, typhoid, pneumonia, and erysipelas. The insanity noted with the secondary fever of syphilis appears to the writer to belong to this group also. The post-febrile pyschoses are presumably associated with two different pathological states, one of asthenia and anaemic of the nerve-centres, the other ana- tomically marked by the filling of the periganglionic and subadventitial spaces with formed elements of the blood. As a rule, illusions and hallucinations, delusions of identity and anxious deliria open the scene; later there may be pleasurable deliria, or ideas of grandeur. A notable feature is the comparative lucidity of the patients during the day; they are then able to reason more clearly, but, in- asmuch as they reason on the basis of their delusive con- ceptions, they are all the more dangerous for this lucidity. It is under these circumstances that patients recovering from febrile disorders commit suicide, usually by jumping out of the window. Episodical attacks of violent frenzy may vary the picture. Most of the patients suffering from post-febrile insanity recover very rapidly, the psychoses ter- minating with a critical sleep or by gradual defervescence, after a course of at most a few weeks. In some cases, how- ever, particularly after rheumatic fever, scarlatina, typhus and typhoid, a more chronic course is observed. The pa- tient's condition oscillates between maniacal and melan- cholic states, and is characterized by great stupidity and confusion of ideas throughout. Even here the prognosis is usually favorable. In some, progressive deterioration sets in, and dementia ensues; in others, fixed and subse- quently systematized delusions remain behind, constituting the case one of delusional monomania; morbid impulses 374 INSANITY. have been observed in others; and in several cases, as was well illustrated in the instance of a post-scarlatinal psycho- sis, the subject of which the writer exhibited before the N. Y. Neurological Society, profound moral imbecility re- mains after the more furibund symptoms disappear. Ma- larial fever is sometimes accompanied by mental disturb- ances which may present a perfect imitation of cyclical insanity, with lucid intervals corresponding to the period between the attacks. A chronic mental disorder, similar to that above referred to as following other fevers, is also noted as a phenomenon of the paludal dyscrasia.* Rheumatic insanity, which is generally considered a dis- tinct form, has many characters resembling those found in the post-febrile group ; in cases where it runs a chronic course, it may terminate in paretic dementia of a kind whose prognosis is somewhat more favorable than it ordinarily is in this disorder. Other forms of insanity with rheumatism as well as gouty insanity, which presents many analogies, are so rare that they will not be considered in this manual. Anaemia is rarely the sole factor in producing insanity; usually other causes are added to it. It may, however, when suddenly produced, as after hemorrhages, be the single and direct cause of stuporous insanity, and is, in its chronic form, undoubtedly the most common cause of this variety of insanity in young subjects. As a rule the anae- mia of other forms of insanity is a result and not a cause of the mental disorder, particularly in simple melancholia and the chronic forms (p. 69). In young girls it is frequently observed that, on the basis of an anaemia, there develops a state of mental anenergy. Such subjects are prone to be- come melancholic, and in two cases the writer has found a genuine stuporous state following the melancholia, so that there was here a complication of two different psychoses. The metallic poisons produce a mental derangement which, owing to its frequent combination with motor dis- turbances, may be confounded with paretic dementia. It is, however, in its typical form characterized by exacerbat- ing deliria of sudden development, and by comatous spells of equally sudden occurrence, which are not found in a * In a case of inherited malarial fever, under the writer's observation, the subject at the a^e of from three to five years had a pleasurable, good- natured delirium, with a surprisingly brilliant flight of ideas, accom- panied by a rise of temperature (103° F.), which on several occasions vicariated for the ordinary febrile attacks. THE SOMATIC ETIOLOGY OF INSANITY. 375 similar association in paretic dementia. The specific character of the metallic tremors will usually serve to dis- tinguish the psychoses due to hydrargyrism and plumbism from the latter disease. Pulmonary affections, particularly phthisis in its last stages, are sometimes marked by mental disorder, usually in the way of alternating depression, emotional mobility, petulance, an intensification of the egotism common to in- valids, and accusatory delirium. Occasionally unsystem- atized delusions of grandeur are found at the height of this: disorder, which is designated phthisical insanity. Valvular disease of the heart is considered by some writers, particularly Witkowski and Leidesdorf, to be a frequent cause of depressed emotional and vague impulsive conditions. The writer has seen no confirmatory example of this, and believes that the view expressed by several of the Germans, that hypertrophy of the left side of the heart with aortic valvular lesion is more apt to be associated with maniacal states, and hypertrophy of the right ventricle with mitral valvular lesion with melancholic states, is sup- ported by too limited a number of cases to merit accepta- tion. Those recorded are devoid of value, as the blood- pressure, which is the intrinsic factor, was not duly registered. The heart has important and direct relations to the brain, and it is very likely that just as disturbances of the vagus innervation are responsible for raptus melan- cholicus — in other words, just as a disordered state of the brain reacts on itself through the medium of the functional cardiac disturbance it provokes — so a valvular lesion may directly influence the emotional states without pre-existing brain trouble. When, however, we remember the large number of persons whose hearts are in the most extreme conditions of organic failure, and who die in consequence, but without having manifested any special psychical dis- order, we will, when we discover a fixed delusion of perse- cution in a subject, with aortic obstruction, look for some other cause, such as an insane predisposition or mental overstrain, as the primary determining element, while the car- diac disorder may be admitted to act as an exciting cause, or, more accurately speaking, to determine the anxious or suspicious character of a delusion. It is a fact that patients suffering from cardiac lesions are more likely to develop anxious and suspicious delusions than those of an opposite nature. 376 INSANITY. Emminghaus * states that in two cases of Basedow's disease (exophthalmic goitre) he found pronounced mental disturbance in the shape of melancholia and periodical mania. The occasional occurrence of this disorder in members of families afflicted with a morbid heredity f would seem to indicate that the physical disease and the insanity are simply collaterals, and that both are the ex- pressions of the same fundamental neurotic vice. It is an interesting problem for the future to solve why enlarge- ment of the thyroid gland should in two disorders such as exophthalmic goitre and cretinism be associated with men- tal disorder or defect. Disordered states of the uterus and ovaries, especially those manifesting themselves in disturbances of menstrua- tion, have been supposed to play an important part in the causation of insanity. It is known, however, that the gross- est lesions of the female generative organs are not compe- tent by themselves to affect the mind to such a degree as to produce insanity. Those pretty cases in which a delusional insanity is instantaneously cured by restoring a retroflected or retroverted uterus to a normal position, do not seem to occur nowadays, and the gynaecological epoch of psy- chiatry seems to have passed by, taking its adieu with the sacrifice at the Blackwell's Island Asylum of Mary Ann Mullen, a sufferer from unrecognized katatonia, on the altar of oophorectomy. J It would have been as reasonable to extirpate the bed-sore of a sufferer from paretic dementia, and to -cut off the haematomatous ear of a terminal dement, with the hope of curing his insanity thereby. Sudden stoppages of the menstrual flow are occasionally found to be the direct causes of a maniacal attack in per- sons not predisposed to insanity, and the mechanism of the psychosis is to be sought for in the thus far physiologically obscure connection existing between the uterus and ova- ries on the one hand, and the encephalic vaso-motor sys- tem on the other. More frequently, persons affected by an hereditary taint suffer from a periodical form of insanity whose exacerbations are determined by menstruation, and *Allgemeine Psychopathologie, p. 371. \A cousin of Guiteau, now residing in St. Louis, was proven at the trial of the insane assassin to be afflicted with exophthalmic goitre. There were in three generations of the family, among the members whose history is known, over a dozen insane and defective individuals. X The ovaries were perfectly healthy. THE SOMATIC ETIOLOGY OF INSANITY. 377 in persons who have what was described in a previous chap- ter as the monomaniacal character, the delusions are often greatly mcKiified by the pelvic disorder. Treatment of the pelvic difficulty is imperatively demanded under these cir- cumstances, and while the pelvic trouble is not the funda- mental cause of the insanity in all cases in which it co- exists, its disappearance is sometimes followed by great mental improvement. The puerperal state, in the wider sense in which Ripping* uses the term, has more important relations to the causa- tion of insanity than the other physiological periods, not excluding those of the two climacterics and of senile invo- lution. During pregnancy itself, peculiar mental states are observed, such as morbid appetites, varying from the ordi- nary //Va to anthropophagous desires; and melancholia is comparatively frequent. The greater frequency of the lat- ter condition in the mothers of illegitimate children, in those who suffer from want, and in those who have a he- reditary predisposition to or a taint of insanity, is a confir- mation of the view to be announced that the physiological accidents to which the human frame is liable are not likely to produce insanity unless its production is facilitated by additional causes. In the writer's experience, melancholia is more likely to ensue during the period of lactation, and is then a psycho- sis of exhaustion, while mania is more frequent with the puerperal period proper. The melancholia due to excessive lactation, or late weaning of the child, and the mania of the puerperal state, which is very often precipitated by sup- pression of the lochia and of the milk secretion, do not differ in any respect from ordinary mania and melancholia. Hence, the writer does not use the terms puerperal mania, or melancholia of lactation, but mania in puerpero and mel- ancholia ^.rAzr/^z//^, to show that no clinical but only an eti- ological distinction is aimed at in the terms employed. Sometimes, especially in older subjects, and when there has been much loss of blood, dystocia, or some emotional de- pression, melancholia instead of mania develops in the puerperal period. In short, sthenic states favor mania, and asthenic ones melancholia or stupor. Occasionally, transitory frenzy is observed, either in de- * Die Geistesstorungen der Schwangeren, WOchnerinnen und SSngen- den. 378 INSANITY. pendence on the extreme agony of child-birth, or as a man- ifestation of the delirium of the parturient state. In this condition, infanticide, or suicide, or both, are sometimes committed. The view has been expressed that when albu- minuria co-exists with the maniacal and frenzy-like explo- sions of the puerperal state, the uraemia is a collateral etio- logical factor. No substantial grounds exist for endorsing this view, and the writer has been able to satisfy himself of the absence of an even approximately constant relation of renal and mental disorder in the puerperal state. The development of monomania has sometimes been ob- served to date from a confinement, but as far as the writer's experience goes, only in predisposed subjects. The relation between organic disorders of the male geni- tal apparatus and insanity is far less constant and important than that existing between the female organs and mental disorder. That a connection between the development of the mind and the male genitals exists, is indisputable. Even if we assume that the defective development of the genital system found in brain monstrosities, idiots, imbe- ciles, original monomaniacs, and the periodically insane, is an accidental accompaniment of the neural mal-develop- ment, we must admit the convincing fact that the early extirpation of the testicles, as in eunuchs and castrated animals, exerts an influence on the mental complexion and development. The frequent delusion of mysterious inimi- cal influences exerted against the sexual power, of sexual mutilation, and of marital infidelity, so characteristic of alcoholic insanity, are believed by Krafft-Ebing to have some connection with the fatty degeneration of the epithe- lia in the seminal tubuli which occurs in old alcoholic sub- jects. The functional abuse of the male sexual apparatus is of more general importance to the alienist than its organic affections. Excessive venery and masturbation have from time immemorial been supposed to be the direct causes of insanity. Unquestionably they exert a deleterious influence on the nervous system, and may provoke insanity partly through their direct influence on the nervous centres, partly through their weakening effect on the general nutrition. That there is a close connection between pathological ner- vous states and the sexual function is exemplified in the satyriasis of mania and the early stages of paretic dementia as well as in the sexual delusion of monomania and the THE SOMATIC ETIOLOGY OF INSANITY. 379 abnormal genital sensations of that condition. In the former case the sexual exaltation is a result, in the latter the genital sensations are collateral phenomena of the psychosis, but there are certain cases in which while an original predisposition may have existed, masturbation is the factor responsible for the production of insanity. While there is no special form of insanity attributable to masturbation, yet those psychoses due to or accompanied and modified by this vice seem to have certain characters in common. Melancholia, stuporous insanity, katatonia, and insanity of pubescence are the forms most frequently found in masturbators, and the essential characters of these psychoses are always recognizable under these circum- stances. The ordinary characteristics of the masturbator are, however, found in addition. Thus such lunatics are usually retired, sly, suspicious, hypochondriacal, indolent, mean, and cowardl3^ They are capital simulators, and develop an art in concealing and in practising their vice which is in remarkable contrast with their stupidity, apathy, and feeble-mindedness in other respects. The prognosis of the psychoses associated with masturbation in males is bad.* A variety of primary deterioration marked by moral perversion is observed in young victims of the habit, which yields to treatment if the habit is abolished. If unchecked it culminates in complete fatuity; this has been observed by the writer in subjects between the eleventh and twenty- third year, and is one of the numerous conditions which passes under the designation of "primary dementia ;" it is the only one to which the term insanity of masturbation can be properly applied. f * Genuine melancholia, usually sine delirio, occurs in female mas- turbators, and has a very good prognosis, probably because the effects of the vice are far less severe in the female than in the male sex, and be- cause it is but very rarely practised with persistency and for long periods by the former. f Gloomy as the prospect of the confirmed disorder is as a rule, yet occasionally very unexpected and happy terminations are seen. Thus, a young man of bad hereditary antecedents, who for days had not quitted his bed, and who exhibited feeble-mindedness and moral perversion, as a result of this habit, was about to be sent to an institution by the writer. The following day, he, suspicious as these subjects are, made a search and found the commitment papers. After perusing them, he immediately turned over a new leaf, went into his father's store, did the best he could, abandoned his bad habits, and to this day, that is, during a period of nearly two years, has filled his position in life with average ability, being remarkable only on account of his taciturnity. 380 INSANITY. In some cases, prolonged and excessive masturbation is observed to result in the formation of a neurotic state, which subsequently serves as the soil for the development of monomania, characterized by hypochondriacal or re- ligious delusions. In the female sex nymphomania is observed to be associated with a similar form of insanity; it has not yet been determined to have that distinct causal relation to monomania which masturbation has in the male. The view held by Maudsley and others that sexual ex- cesses are the all-important factors in the etiology of pa- retic dementia, is not sustained by the writer's observations. Frequently such excesses are committed by paretic de- ments in the earlier exacerbations of their malady, as well as in the earlier period of simple mania; but while they un- doubtedly precipitate the progress of these disorders, they must be regarded as phenomena and not as causes. The influence of neuralgia and pain in the production of insanity is limited to the occasional development of transi- tory delirium or frenzy, analogous to that observed in the puerperal state. Schuele has promulgated an utterly fanci- ful view as to the existence of a " Dysthymia neuralgica," under which head this author believes that most of the psychoses may be ranged. It is safe to say that this theory will not be accepted by alienists until it is supported by more convincing testimony than that thus far adduced in its favor. While a vast host of other somatic ills might be enumer- ated, which have all been shown to have an influence in the production of mental derangement, yet, multitudinous as these causes are, composing as they do a twenty-fold longer list than the psychical causes, it is after all but a small percentage of the insane who owe their trouble to their in- fluence alone. Blandford,* with approximate accuracy and little elegance of diction, says: " Men and women become insane because it is their nature and constitution to develop insanity, and when we hear that this or that has caused their insanity, it is often their restless and half-crazed brain that has made mountains out of molehills, and given an objective existence to troubles and vexations which exist in their minds subjectively, and have no outward reality what- ever." It is true, as stated in this extract, as also at the * " Insanity and its Treatment," p. 153. THE PSYCHICAL CAUSES OF INSANITY. 381 Opening of this chapter, that the inherited and acquired in- sane constitution is the fundamental factor in most cases of insanit3\ This conclusion, and the assumptions based on it, do not, however, justify us in ignoring the physical dis- eases immediately preceding or associated with insanity, for there is more satisfaction to the practical alienist ni remedying one case of mental disease by removing its physical cause, than in diagnosticating a hereditary predis- position in ninety-nine incurable ones. As to Blanciford's concluding allegation that the brain of the insane " gives an outward existence to troubles and vexations which exist in their minds subjectiveh% and have no reality whatever," it applies to the fully developed disorder and not to the preincubatory period of mental derangement. CHAPTER V. The Psychical Causes of Insanity. There are a number of cases on record in which a sud- den emotion, like anger, fright, or excessive joy, has led to the immediate development of insanity, either uncompli- cated or associated with epilepsy. Transitory frenzy has been in several instances noted to follow angry excite- ment, while stuporous insanity and katatonia can in a comparatively large number of cases be traced to emotional shock of some kind. The manner in which these causes operate is still obscure. Some are inclined to attribute in- sanity resulting from them to the vaso-motor disturbance induced by emotional episodes. The writer believes that in the case of stuporous insanity the production of the functional suspension of all the mental faculties is com- parable to that anaesthesia of the retina which results after sudden exposure to a very dazzling light. An external impression if it exceeds the physiological receiving power of a nerve centre, provokes a functional blunting of that centre for impressions of lesser intensity, and this applies to emotional influences as well as to more coarsely material ones. Ordinarily the psychical causes of insanity do not act in as direct a manner as in the case just cited. It is usually 382 INSANITY. only after a succession of assaults continued through a number of years that the mental organ breaks down. Worry and disappointment, hopes long deferred, and the attendant conflicts of the inner man, the continued result- ing over- strain of an organ whose physiological state is one of equilibrium, constitute already a pathological state, a functional abuse of the brain. The intimate relation between the mind and the body is shown by the somatic disturbances which ensue. A not improperly so-called nervous dyspepsia, constipation, and functional disturbance of the heart and kidneys are common sequelae of prolonged emotional over-strain, and all of them react on the organ whose functional disturbance is in the first place respon- sible for their existence. Headache, sleeplessness, 7naiaise, a tendency to empty speculation either in the way of hypo- chondriasis, suspicion of others, or distrust of self, so com- mon features of the prodromal period of insanity, mark this reaction, and are in part due to the continuance of the original emotional causes, and in part to the somatic state they have provoked. This preliminary period of insanity, as it may not im- properly be termed, may last for years without leading to serious developments, and it undoubtedly disappears or becomes latent, with or without treatment, in a far larger number of patients than those who become actually insane. It is those who have an hereditar)'^ predisposition, or who resort to stimulants and narcotics, lending a spurious vigor to the exhausted nervous apparatus, who furnish the largest contingent to our insane population. In case there is an hereditary predisposition, monomania, periodical mania, or melancholia are likely to develop. In case alcoholic or sexual excesses are superadded, paralytic dementia may result. In uncomplicated cases the insane explosion is usually in the form of a mania or melancholia, the development of one or the other being probably dependent on the constitu- tional tendency of the patient, whether this be in the direc- tion of sthenic or asthenic reaction to pathological causes. Intellectual labor is but very rarely a factor in the causation of insanity. It is only where the mental or- gan is weakened by physical disease and thrown off its equipoise by emotional crises, that mental labor exerts an injurious influence. If persisted in under these circum- stances, primary deterioration is likeh^ to appear. Aside from this case, mental labor of a proper kind is, so THE PSYCHICAL CAUSES OF INSANITY. 383 far from being a cause of insanity, one of the most efficient prophylactics against mental disorder. More than one member of an insane family has been prevented from join- ing his relations in the asylum by some fortunate accident which threw a routine occupation in his way. It is with the mind as well as with the body, a proper degree of exercise is essential to its health, and philosophers and scientists who have been free from worry and vexation, and have pursued the even tenor of investigation and reasoning, have been and are noted for reaching advanced years with- out manifesting any mental decay, or much less than other persons at the same period of life. Humboldt, Darwin, Cuvier, not to mention a host of others, are examples of this fact. On the other hand, poets, musicians, and artists rarely reach advanced years without manifesting deterio- ration, and contribute not a little to the insane population, if, indeed, many do not join the ranks of these professions because they have a taint of that insanity which is supposed to be allied to genius in them. While the greatest poets and artists have been persons of the highest mental integrity, it is best to discourage persons who have a predisposition to insanity from cultivating the higher arts. Lenau, Holder- lin, Cowper, Byron, Poe, and a number of others, are illustra- tions of the association of this tendency with the hereditary taint, and, in part, of its unfavorable influence. Our daily experience shows that even in the cultivation of the mechanical arts, and of the strictly scientific branches, there is room enough for the play of insane project-making and delusions. Dilettantic aspiration is the foe of the insanely disposed in every branch of the arts and sciences; the insane inventors, political, socialistic, and scientific would-be re- formers crowding the quiet wards of some institutions strikingly demonstrate this. The influence of mental and emotional over-strain in the production of mental derangement of certain types, has been discussed in Part Second (Chapters XI and XV). It remains for us to refer to the influence of education on the development of the mind in its relations to insanity. The earlier an injury affects the nervous centres the more pro- found are its results. This is illustrated, as to organic affections, by such examples as the porencephaly of Heschl. When this lesion involves the brain of a child, imbecility results, but when it is produced in the brain of the adult, the mind may remain unaffected. It is the same with the 384 INSANITY. functional abuse of the organ. The earlier emotional over- strain, harsh treatment, sensational reading, and ambitious rivalry occur in the history of mental development, the more likely are they to awaken the slumbering predisposi- tion to insanity where it exists, or to develop it where it does not exist. The most important task of the alienist of the future will be a thorough revision of our educational methods. There can be little doubt that competitive ex- aminations, mechanical grinding of the "spelling match" variety and the " Gradgrind " principle will be among the things that were, after that revision is made. CHAPTER VI. The Medicinal and Dietetic Treatment of Insanity. It may be accepted as a dogma of psychiatry that the leading morbid phenomena constituting insanitj' can be influenced by drugs in only very exceptional instances. As a rule, drugs act, when they act at all, indirectly, although a few of them seem to influence the fundamental patho- logical state of alienation, especially when located in the vaso-motor system, most happily. Among the general objects of medicinal and dietetic treatment are the improvement of the general nutrition and the remedying of insomnia. The chief field for this branch of therapeutics is consequently among the acute forms of derangement. In disorders of the sthenic type like mania, when the chest organs are in a sound condition and the general nu- trition is goodj the medicinal treatment is mainly limited to the control of motor excitement and the relief of insom- nia. The best, most reliable, and safest drug for the former purpose is comum, the only reliable preparation obtainable being Squibb's fluid extract.* As a rule, twenty minims will suffice as a first dose, while from ten to fifteen minims may be subsequently given every half hour or hour until the excitement is subdued. In patients whose tolerance of the * It is necessary to test every new sample, as the strength of the preparation varies. THE MEDICINAL TREATMENT OF INSANITY. 385 drug has been tested, much larger doses may be safely ad- ministered. In one case the writer has known death to ensue in a debilitated patient who took a drachm of the drug, through the negligence of an attendant, while the same dose was repeatedly found to fall within the physio- logical limits in its effects in others. The physiological action of conium is still the subject of discussion. The writer, from his observations, is inclined to believe with Harley, Davidson, and Dyce Brown that it acts on the cere- bral centres, and not alone on the peripheral nerves as Kol- liker and Guttmann claim. In maniacal patients it is truly remarkable to find how rapidly with the progressing aboli- tion of muscular overaction the mental processes become clearer and the flight of ideas less rapid just prior to the patient's dropping off into what usually proves to be a re- freshing slumber. No drug in the whole range of those used in insanity is so certain in its action and leaves so few ill effects behind as conium. Patients who stagger around under its influence, and are compelled to take to their beds and become tranquil in consequence, awake some hours thereafter in a condition of comparative improvement. It is advisable not to push the drug after the first indications of motor relaxation are observed, but to watch it most care- fully then. A combination of equal parts of bromide of potassium and chloral* is the best medicinal remedy for the insomnia of maniacal patients. The necessary dosage varies so greatly that it is impossible to prescribe any rule. With a patient of good physique, and whose organs are in a sound condition, it will be simply useless to give the amounts ordinarily given for insomnia in private practice ; the double, nay the treble, must be given; and better to pro- duce one good night's or half night's rest with a single large dose than to fail repeatedly with a succession of small doses, whose aggregate amount and whose permanently injurious influence is much greater, while they fail to pro- duce the good effect of a single large one. Neither of these drugs should be used night after night, except in emergencies or in epileptic insanity, for it is not so much the object of the alienist to crowd down a psychosis as to establish a series of relatively lucid periods, and thus to tip * Not of two or three parts of the former and one of the latter, as is frequently recommended. 386 INSANITY. the scale sufficiently on the side of struggling nature to overcome the pathological influence. He should bear in mind that mania disappears, not suddenly, as a rule, but by a series of oscillations between the healthy and the diseased state, which finally merge into a healthy equilibrium, and that in the absence of a specific remedy it is wisest to fol- low physiological lines of treatment. No mania was ever choked down, but, at most, prolonged or diverted into the channel of deterioration by the excessive use of hypnotic and calmative drugs. It is even desirable to permit a ma- niacal patient to remain excited at some periods and within certain limits, as only under these circumstances can that men- tal influence which is often more important than the drug be tested and exerted so as to permanently benefit the patient. In paretic dementia it should be particularly carefully watched, and in the later stages of that affection is al- together contraindicated, owing to the fact that it may in- tensify the angio-paralytic phenomena of that disease, or produce cardiac paralysis directly. Among the procedures which are recommended for the treatment of sthenic delirious conditions, and of such which, like diiirium grave, are associated with incipient and acutely inflammatory states, venesection at the mastoid process, the use of ice-bags, the cold pack, baths, and of hydragogue cathartics are the most efficient. \'enesection is very rarely applicable, because the period when it might be useful is usually past when the patient comes under the alienist's cognizance; its use should be limited to cases of suppressed menstruation and grave delirium. In insanity with excite- ment we have usually to deal with a condition rather of undernutrition than of over-nutrition, and it is in obedience to a rational meditation on this fact that phlebotomy and the leech are almost banished from asylums for the insane.* The use of baths, originally recommended by de Bois- mont in recent cases of mania and melancholia with ex- citement, is most beneficial. Baths of nearly the temperature * The leading expert for the prosecution in the Guiteau trial, who had up to that time enjoyed a well-deserved reputation as a gynaecologist, evidently stimulated by his forensic achievements as an alienist expert on the occasion referred to, applied venesection to a case of melancho- lia (!), and reported an almost instantaneous recovery. The case was cer- tainly one illustrating the influence of mental impressions, and signifi- cantly demonstrates that it was simply an instance of hysteria. Vene- section in true melancholia would be as justifiable as venesection in post- partum hemorrhage. THE MEDICINAL TREATMENT OF INSANITY. 387 of the body, and which may, in well-nourished maniacs, be prolonged for twelve hours and over, exert an excellent calmative and sometimes a better soporific effect than the medicinal calmatives. The cold pack is also useful in mania and agitated melancholia in a double way: first, because of its effect on the vaso-motor system; and second, because of its effect on the metabolic processes, and consequent curative effect on anaemia, if present. Neither the bath nor the cold pack should be used in patients whose temperature is below 98°, and on the whole they are less frequently applicable in melancholias than in manias. It will be found an excellent plan to alternate in the use of narcotic and hydro-therapeutic calmatives, in order to prevent the patient from becoming accustomed to the influence of either. In conditions like the exacerbations of paretic dementia, of which vaso-motor paralysis is a feature, ergot is very useful. The elaborate researches of Kiernan, undertaken with this drug at the suggestion of the writer, prove that it has a marked influence both on the status-like epileptiform and on the maniacal seizures of this disease. Amyl-nitrite is indicated in the opposite condition;* and as this drug, which on account of its evanescent action must be repeatedly given, effectually remedies vaso-motor spasm, it is of great service and sometimes directly curative in stuporous in- sanity and melancholia, particularly of that kind in which the "frozen attitude" occurs. Quite magical effects have been seen by the writer in cases of katatonia. In the first patient selected for trial, who was in the cataleptic phase, complete lucidity occurred immediately after the first in- halation; the cataleptic state recurred in an hour, and as quickly yielded; and the persistent use of the drug ma- terially hastened the patient's ultimate recovery. In apa- thetic stuporous and cataleptic patients it is necessary to resort to the device of closing their nostrils and mouth for a few moments before presenting the amyl-nitrite to be in- haled, in order to compel the patient to take a deep breath. One or two deep inspirations mediate a more thorough action of the drug than twenty superficial ones, and it is for the reason that they neglect this precaution that physi- * The writer is aware that this drug is recommended by some English writers for the epileptiform seizures of paretic dementia. Although its use is sometimes followed by a cessation of the fit, it is difficult to see how, in view of the angio-paralytic action of the drug, any other but a deleterious influence can be exercised by it in this condition. 388 INSANITY. cians so frequently fail in its use. The patient's face must flush and his pulse become full and expansive, or the drug has not been properly given. Happily, the very conditions in which it is of service are the ones in which the greatest tolerance is shown to it. Only in elderly subjects and those having arterial disease should its use be proscribed. Opium is the most generally useful of all drugs in in- sanity. It has a direct influence on the mind, antithetical to the painful emotional state of melancholia and to the persecutory delirium of monomania. While it is itself a vascular stimulant, yet its influence on the heart is such as to overcome the wiry pulse of extreme melancholia and other conditions in which the blood current in the brain may be assumed to be diminished. It is because of the peculiar union of a vaso-constrictor influence with its well-known effect on the heart, that it of all generally stimulating nar- cotics is applicable to paretic dementia, and that we have the, to a superficial view, paradoxical fact, that Avhile opium and morphia are counterindicated in manial furor, they are strongly indicated in the furious exacerbations as also in the quiet intervals of paretic dementia. Morphia is of ex- cellent service in the treatment of periodical insanity whose exacerbations it may entirely check. As a rule it is best to give opium and its preparations by the mouth, for pa- tients with persecutor}' or hypochondriacal ideas are very apt to interpret a hypodermic injection as an assault, an impregnation with poison or in some other delusional wa}', and it is a daily experience with the insane that the start- ing of a suspicion or a new train of delusions will undo the best therapeutical measures. Whether it is for this reason or some other, opium does not act well in passive melan- cholia. The deodorized tincture of opium and the bimeco- nate of morphia are the best preparations, and while opium produces constipation, and it is necessary to give a gentle cathartic with it at first, yet when its prolonged use is neces- sary it will be found that the intestinal canal soon resumes its functions, or at the worst that these can be readily regulated. In the maniacal periods of paretic dementia very large doses are borne. In melancholia and anxious states generally it is best to begin with twenty minims, and continue giving from ten to fifteen minims every two hours, till an effect on the pupil and pulse is obtained. In nearly all the conditions in which opium is admissible digitalis or convallaria can be advantageously given. It THE MEDICINAL TREATMENT OF INSANITY. 389 may be accepted as a rule in insanity that the administra- tion of both these drugs should be guided by the condition of the heart. Opium should not be given, or at least not given without digitalis or convallaria, in cases where serious valvular lesion and dilatation exist, and digitalis should not be given when there is high arterial pressure, nor in one condition which is very rare in the asylum ward — cardiac hypertrophy. The most recent fashion in psychiatrical therapeutics is the use of hyoscyamia. The large doses of this drug rec- ommended by the English, and the still larger ones, em- ployed by a few American physicians, are calculated to stagger one. Schiile expresses a natural surprise at the in- discriminate abuse of this drug, and sounds a well-timed warning as to the toxic effects, such as aphonia and ataxia, occasionally observed to follow very small doses of hyoscya- mia. Until a more careful study of its effects shall have been made, the writer would hesitate to recommend it, as long as we have so many tried reliable and safer remedies at our disposal. The tincture of hyoscyamus has been long given by Kiernan in combination with chloral hydrate and bromide of sodium as a calmative of excited patients; and the writer is unaware of any good effects obtained from hyoscyamia which are not obtainable from this much safer combination or from that with conium. Billod claims to have obtained excellent remedial effects in the treatment of hallucinatory conditions by means of stramonium. The writer has no experience with this drug, but its advocate's position entitles the drug to a more ex- tensive trial than it has thus far received. Cannabis indica, in large doses given at intervals of two or three days, sometimes has an excellent effect on de- pressed states, and its influence in some cases is rapid and strikingly manifest. In a case of folie du doiite its influence seemed to mark the turning point in the favorably termi- nating history of the case. Unfortunately the unreliability of the preparations obtainable in America is a bar to its use, and even the English extracts so highly praised on both sides of the Atlantic are often inert. Strychnia is one of those drugs which, while they exert no specific influence on any special morbid factor of insan- ity, rank high as general tonics in this disorder. Its excel- lent influence on the tone, both of the voluntary and involun- tary muscles, is shown in all conditions of motor anenergy, 390 INSANITY. and visceral torpor; hence its use is to be recommended in melancholia, stuporous insanitj' and other states of neural depression, as well as in all conditions in which the sphinc- ters are relaxed. It has also a favorable effect on states of vaso-motor paresis, such as paretic dementia and the later periods of grave delirium; it is hence indicated wherever ergot, with which it may be advantageously combined, is applicable. In conditions with high vascular tension its use- fulness is problematical, and in melancholia with the " frozen attitude" which is associated with a spasmodic state of the entire muscular system, and regarding the influence of strychnine on which the writer has no observations at his dis- posal, it will be well to employ it very carefully. It would be hasty, however, to assume that a spasmodic state due to a mechanism altogether the opposite of a central state of func- tional over-activity must necessarily be influenced unfavora- bly by a drug which produces spasm through such a mechan- ism. Strychnia is the most general neural stimulant at our disposal; its tonic influence is exerted on the entire central nervous apparatus, and is not at all chiefly localized in the cord, as some have believed.* It stimulates the central and peripheral sensory and the central motor and the vaso- motor systems, and directly affects the cerebral functions in a favorable way. Nowhere is this better manifest than in paretic dementia. The effect of strychnia is somewhat lessened by a prolonged administration; in addition, while the appetite is at first very happily influenced by it, it is afterwards unfavorably affected; for all these reasons, it is best to give nux vomica and strychnia on an " interrupted plan." The drug should not be suddenly administered in large doses, but in rising ones, till the desired physiologi- cal effects are obtained; then they should be gradually de- creased, each cycle of administration lasting about ten, with intervals of five days. As a general rule, the combination of several drugs in a mixture, intended to be constantly used even in the treat- ment of one and the same patient, is to be deprecated. Under these circumstances it is impossible to regulate the administration of remedies which, like those used to quiet * The writer in the course of a large number of experiments performed on animals of all classes (" The Anatomical and Physiological Efifects of Str^'chnia, on the Brain, Spinal Cord, and Nerves;" Prize Essay of the American Neurological Association) found that the characteristic spasms of strychnia poisoning are in part at least of a cerebral origin. THE MEDICINAL TREATMENT OF INSANITY. 39! insane excitement, must more or less closely approach in their effects the boundary between life and death. To com- plicate the sufficiently difficult .task of approaching this limit sufficiently near to obtain the useful effects of a drug on the one hand, and not to pass beyond it on the other, by combining it with remedies which may or may not mask or neutralize its effects, is exceedingly unwise. What is- useful in the way of combination in psychiatry has been; tested in general practice, as for example the uniting witb opium of a slight amount of belladonna. As to the harmo- nious combination of chloral hydrate and bromide of so- dium,* the general caution must be made, that the nearer the patient approaches confusion or moria, the less bromide must be given to him; and in such cases it may be well to give the chloral alone. Unless there is an emergency de- manding the instant calming of a boisterous or destruc- tively maniacal patient, it is best to regulate the functions of the gastro-enteric tract before proceeding to administer any drugs, and when administering them to bear their pos- sible influence on the digestion continually in mind, and to regulate their administration accordingly. In the majority of cases, the neurotic medicines are better absorbed and better borne in an alkalinized stomach than in one contain- ing either an acid gastric juice or the acid products of fer- mentation found in some forms of gastritis. This is par- ticularly the case with chloral hydrate and the bromides. Both the hypnotic purpose and the "gastric" indications are met better if a glass of hot milk is given immediately after the chloral and before retiring. Alcoholic stimulants are of great service in all states of depression and restlessness, excluding those of a maniacal character. Their use is therefore contraindicated in the active phases of paretic dementia, and they should be spar- ingly used, if at all, in the quiet intervals and remissions of that disorder. They should never be given in periodical lunatics, without bearing the danger of the formation of a dipsomaniac tendency by them in mind. Malt liquors in moderate quantities, not exceeding, say, a half a pint of beer, ale, or porter daily, will be found useful both as nutrients and as calmatives in badly nourished subjects, suffering from insomnia. They should not be administered unless * Which takes the place of bromide of potassium in every respect, and disturbs the stomach less. 392 INSANITY. the patients have out-door exercise at the same time, and the slightest sign of gastric catarrh is a contraindication to their use. Phosphorus has been recommended on theoretical grounds in all forms of insanity. The belief in its virtues was of course strongest in those days when it was believed that the " phosphates" are continually drained from the brain through the urine, and that the chief functional sub- stance in the brain is a phosphorized oil or fat. But the dictum that " without phosphorus no thought," correct as it is, does not lead to the conclusion that phosphorus is to the brain in insanity what iron is to the blood in anaemia, as if delusions, hallucinations, abulia, and amnesia were comparable to strikes in a match factory. Undoubtedly the restorative nutrition of the brain is an important task for the psychiatrist, but he may crowd phosphorus into the stomach, without materially influencing abnormal mental processes. It is true that the symptoms of mania and melancholia are probably the expressions of disturbed biochemical states of the brain tissue, but we are not able to put our finger on any one component element, and say that this one is too rapidly wasted, and that one not rapidly enough removed. Even if we could do so, we might be power- less to control the vaso-motor disturbance so intimately connected with the biochemical anomalies. As it is, the chemistry of the brain has taught us nothing regarding the particular role which phosphorus, in the combination of a distearyl-glycerin-phosphoric acid combined with neurin as a base, plays in acute insanity. We are limited in our indications to empirical observations, and these teach us that in the deteriorating mental states, as well as in those associated with general nervous exhaustion, phos- phorus is of considerable benefit. The problem of furnish- ing a reliable and easily assimilable preparation of phos- phorus has not been satisfactorily solved. The trade-mark preparations are some of them very well borne by the stomach, but inconstant in strength, and, in two prominent instances at least, not honestly kept up to their original standard. Iron is indicated in that large class of the insane in whom anaemia is present. No other rules are required for guidance in its administration, or for the administra- tion of other restorative remedies, than those followed in general practice. THE MEDICINAL TREATMENT OF INSANITY. 393 Quite extravagant hopes have been based on the alleged curative effect of electricity in insanity. Superficial theor- izers have even undertaken to indicate the special kinds of current, and directions of such, to be applied to the head in various forms of insanity, and it is to be presumed that the more modern imposition of static electricity will come into vogue, and after a brief sway over the minds of the credu- lous, and an occasional success with a simulating or hys- terical patient, share the fate of other epidemics of char- latanism. Electricity can have from the very nature of the case no specific effect on insanity.* Its applicability is limited to those forms in which there is simple atony, as in stuporous insanity, and to those which are associated with organic and functional disease of the nervous axis; in the latter case the ordinary rules of electro-therapy apply. In stuporous insanity its effect is to stir up the patient; but we should be very sure of our diagnosis before applying it, and not confound atonic melancholia with stuporous in- sanity, for in a melancholic patient electrical manipula- tions would probably provoke additional delusions of per- secution to those he already entertains. If we were acquainted with the molecular condition of the brain in health and disease, and if we understood better the exact influence of electricity on the molecular and dynamic states of that organ, we would be better able than we now are to formulate the indications for the use of this potent neurotic agent. The diet of insane patients should be nutritious and easily assimilable. In view of the frequent coexistence of gastro-intestinal disturbance, milk and raw meat f should * Unless we are to assume the correctness of such dicta as the one con- tained in the following citation from the testimony of the prosecuting witnesses in the Guiteau trial (p. 1363, Dr. H. P. Stearns testifying): Question. What is your theory of a person becoming suddenly insane through the excitement of fear in its operation on the brain ? Answer. I suppose that to be injury of the tissue of the brain from the effect pro- duced upon it as communicated to it. Question. By the blood rushing to the brain or withdrawing from the brain ? Answer. It is very difficult to say what precisely does produce the effect. // may be from a change j'w the electrical currents that we know pass through the brain. f The tender parts of beef, excluding the fatty and tendinous intersec- tions, are scraped with a blunt knife in such a way as to retain the juice; the mass is then seasoned with an abundance of salt and a little pepper. Of course it should not be attempted to give this palatable and nutritious dish to patients who have the delusions that they are compelled to eat human flesh, or meat seasoned with the blood of their friends. 394 INSANITY. be the chief food of depressed patients. Most vegetables and the prepared meats are commendable only in patients who at least occasionally take out-door exercise. Very good results have been obtained by the writer in epilepsy with and without insanity, by compelling a strictly vege- tarian diet, as recommended by Browne, and this doubtless will be found applicable in the case of asylum patients. More attention than is ordinarily paid to this branch of the subject should be devoted to the examination of insane patients with reference to the existence of any disorders associated with defective or perverse assimilation ; the proper treatment of lithaemia and allied conditions will often prove radically remedial. Melancholiacs, paretic dements and monomaniacs labor- ing under delusions of persecution will frequently refuse food, fearing that it will injure them {sitophobia), while patients in atonic and stuporous states are simply unable ta eat. Sometimes maniacal patients refuse to eat, but as a rule only for a short time, and their refusal rarely becomes a problem for the alienist to seriously consider. When a melancholiac refuses food, the rule is to compel him to take it forthwith. With maniacs, monomaniacs and paretic dements, temporizing is advisable, because these patients usually resume eating voluntarily, and for the additional reason that their anorexia is often due to a gastric disorder' which can only be favorably affected by rest of the organ affected. With many of the sitophobic patients it sufF.ces to lead them to the table, to put the utensils for feeding in their hands, or to feed them with a spoon. With a large number of melancholiacs and monomaniacs, with inspira- tional delusions of commands to abstain from eating, it is necessary to resort to artificial feeding. Temporizing, ad- missible under other circumstances, would here be injurious. Particularly in melancholia the nutritive disturbance is so great that not a day should be lost in waiting — frequently in vain — for a resumption of the physiological habits. The most simple and most readily extemporized apparatus for artificial feeding consists in a funnel, to whose lower end an oesophageal tube is attached. The tube, well oiled, maybe passed through a nostril, or through the mouth with the aid of an oral speculum. The latter should be of strong make. In passing the tube backward the index finger of the disen- gaged hand should be used as a guide. In passing it through the nostril, the possibility of its entering the res- THE MEDICINAL TREATMENT OF INSANITY. 395 piratory passages should be borne in mind. This accident provokes coughing, strangling, and cyanosis; the two for- mer warnings may, however, be absent in paretic dements with laryngeal anaesthesia. Coughing and strangling may ensue through irritation of the pharynx even when the sound is passed properly, but in this case there are never any in- spiratory noises produced in the tube; expiratory noises may occur when the tube is properly passed by escape of gas in the stomach. The food used in forced feeding should always be strained before being poured into the funnel, and should never be used at a temperature above or much below that of the body itself. Milk, yolk of eggs, dry wines, milk- punch, egg-nog, beef-juice, and hydroleine are among the substances which can be conveniently administered in this way. Medicines can also be given mixed with the food, and as this is done without the patient's knowledge, is often a great advantage with a suspicious lunatic. The advantage of the funnel over the stomach-pump, which is frequently used, is that less pressure is employed, that the apparatus does not appear as formidable to a sus- picious patient, and that the attendants, if feeding should be entrusted to them, will not be tempted to omit the im- portant precaution of straining the food. The stomach pump permits the operation to be done more quickly, and with it, obstruction caused by a blocking up of the tube may be overcome by force. It should be recollected, how- ever, that nausea and vomiting are likely to ensue in case the food is introduced too rapidly. Whether fed with the funnel or the stomach-pump, the patient should sit up, and if he is very obstructive a restraining chair will save the pa- tient much needless muscular exertion, the physician much trouble, and diminish the chances of doing an injury. In case the oesophageal tube is passed along the floor of the nasal cavity, it is apt to encounter a resistance and be de- flected forward by a prominence which is sometimes very marked on the posterior pharyngeal wall, and which corre- sponds to the bodies of the cervical vertebrae. Dr. Tuke advises throwing the head of the patient back at the mo- ment when the sound approaches the posterior nares, the tube having previously been bent a little so as to facilitate its downward passage; then at the moment when it is about to glide down into the oesophagus, when there is a risk of its passing into the larynx, he advises the head to be brought forwards and downwards so as to send the point against 396 INSANITY. the posterior wall of the pharynx. After passing the upper end of the oesophagus, the tube is usually swallowed, as it were, and glides down without further difficulty into the stomach through the action of the constrictor muscles. At least sixteen inches of the tube should be allowed to pass down before raising the funnel or using the syringe. Some patients are artful in resisting forced feeding, learn- ing to use their abdominal muscles in such a way as to com- press the stomach and cause the food to regurgitate. This is rarely the case in acute melancholia, more common in monomaniacs with certain delusions, and patience as well as a judicious denial of certain privileges will be necessary to prevent the patient from carrying out his project of self- starvation. It is frequently found that after having fed a patient by force several times, the sight of the feeding paraphernalia when brought in for use will induce him to eat voluntarily. It is therefore well in every case to make the proffer of food before resorting to extreme measures, and if it is taken, it may be advantageous to leave a little solid food in the room as if by accident. In that case it will be found that the patient will eat it stealthily, when he supposes him- self unwatched. It is needless to add that no food should be left in the patient's room, under these circumstances, to eat which he would require a knife, fork, or spoon, or any vessels of porcelain, glass, or tin, which he could break and open his blood-vessels with; wooden platters will fulfil all the requirements of the case. Forced feeding should in stuporous and atonic patients be resorted to at least three times a day, and, if it can be done, once at night. The nutritive loss is something enor- mous in these cases, it is startling even in the best-fed pa- tients, and it is the duty of the physician to fight the foe for every ounce of body-weight, as it were. With other patients, feeding by force will be necessary, at most, twice a day, and rarely will they require it for long periods. It should always be done under the physician's immediate or- ders. The additional demand has been made, that it should always be done in his presence, or by him in person. The writer has, however, seen trained and other nurses perform the operation with all the skill and judgment which the case could possibly have required, and many members of our profession could afford to learn the practical details of the operation from them. An anatomical demonstration of THE PSYCHICAL TREATMENT OF THE INSANE. 39/ the parts involved should be given to every person to whom forced feeding is intrusted; with this, and experience ac- quired undei' skilled guidance, he may be safely relied on to carry out forced feeding himself, and without any other aid than that of another and older attendant. It is unnecessary to specify here the hygienic require- ments of the insane, which are those of hospital patients generally. Patients who are anaemic, and particularly those whose temperature is subnormal, should be in warmer apartments than ordinary hospital patients, or those whose disorder is of a sthenic type. In this climate a temperature of from 65° to 68° Fahrenheit, and in some cases even higher, is necessary in the wards where demented and melancholic patients are congregated. CHAPTER VII. The Psychical Treatment and Management of the Insane. The subject of the psychical treatment of insanity in its widest sense comprises the prophylactic treatment of the insane predisposition. This vast subject it is impossible to treat of in a manual, and the writer contents himself with expressing his opinion that in the future certain educational means will be recognized to be as essential for the diverting of the mind inclined to perversion into healthier channels, as the methodical training of certain muscles is essential in preventing and remedying certain of the malformations which come under the cognizance of the orthopoedist. The physician is ordinarily called upon to treat the fully developed disease, and the question of most pressing importance which presents itself is whether the patient can be treated at home, or whether it is necessary to send him to an asylum. In the case of primary deterio- ration, of stuporous insanity, and of the earlier phase of syphilitic dementia, this question may be frequently de- cided in favor of home treatment, provided all the conven- iences for psychical and physical treatment are within the reach of the family. In most other forms of insanity the physician risks very little by positively recommending asy- 398 INSANITY. lum treatment. He has three important questions to con- sider: ist. The safety of society ; 2d. The physical and financial safety of the family; 3d. The interests of the pa- tient as an individual. Ordinarily the duty of the physician is in the first place towards the individual patient; in the case of insanity, however, there are many other interests than those of science, and of abstract humanity to the pa- tient, involved. Where we have to choose between the en- dangering of the security, health and happiness of healthy and useful members of society on the one hand, and the compliance with sentimental considerations advanced in favor of decrepit, dangerous, or possibly useless ones, we need not hesitate long in our choice — no longer than the obstetrician when called upon to decide whether he shall perform an operation w^hich would prove the certain death of a mother and the possible salvation of her unborn child, and another which would result in the death of the child but certain salvation of the mother, will hesitate to adopt the latter alternative. Fortunately, the alienist is in the position, when complying with the first two demands enu- merated, of acting at the same time in the best interests of the patient himself. The patients suffering from the ordinary psychoses are dangerous to society in the following ways: ist. They may commit homicide, either under the influence of hallucina- tory terror of imaginary pursuers, insane hatred of rivals in their affection, or of alleged seducers of their partners in life, an insane desire for notoriety because of disappointments in insane aspirations, or under supposed inspiration from on high. 2d. They may commit arson or incendiarism either from similar motives as those just enumerated, in the thoughtlessness and carelessness of dementia, as the result of morbid projects — for example, when a paretic dement burns down his house to build a palace in its place — or in obedience to the pyromaniac morbid impulse. 3d. They may make delusional charges, or false charges from mali- cious motives, against others, and procure the punishment of innocent persons. 4th. They may make indecent assaults, either on account of satyriasis, or sexual perversion, and scandalous exposures of their persons from sexual motives, or in the abstraction of dementia. 5th. They may destroy valuable property under the influence of delusions or insane antipathy. 6th. They may propagate their disorder. Luna- tics are dangerous to' their families because: ist. They may THE PSYCHICAL TREATMENT OF THE INSANE. 399 in the abject gloom of melancholia, or in obedience to the morbid impulses of that condition, immolate whole fami- lies in a general massacre. 2d. They may squander their property in insane speculation, absurd purchases, or in ex- cesses. 3d. They may develop mistrust against members of the family, commit murder and mutilation on them, or be- come the instruments of designing persons, and disinherit or rob those who are naturally dependent on them. They are dangerous to themselves: ist, On account of suicidal inclinations; 2d, through the occasional tendency to self- mutilation; 3d, through the continuance in a course of con- duct and excesses which are calculated to intensify and prolong their malady. All these considerations demand that the insane, who are liable to indulge in such acts, should be beyond the range of damage to themselves and to others; and in a large number of cases the experienced alienist feels relieved of a heavy sense of possible danger as soon as the patient is within the walls of a properly conducted asylum. An asylum sojourn has in the vast majority of cases a good effect on the insane. Curable patients are never in- jured in their prospects as to curability in a medically well- managed institution, and incurable patients should be there for practical reasons, and are usually better off in than out of the asylum. The advantages of asylum treatment are the following: I. Refusal of food and medicines — the great obstacles to the treatment of the insane outside of asylums — are best dealt with by a skilful corps of physicians and attendants always on the spot, with the necessary appliances at their disposal. 2. The necessary supervision of the insane at all hours can be carried on with the least expense and greatest thoroughness in the asylum ward. 3. The excessive and damaging use of narcotics, calmatives, and restraint, neces- sary for the purpose of preventing scandal in the neigh- borhood, and noise, destructiveness, and exhaustion at home, can be dispensed with in the asylum. 4. The sojourn of a patient in an asylum, the continual reminder which the restraint of its walls is to him that he is considered in- sane — whether he believes himself to be so or not — is in many cases a far stronger incentive to a kind of reflection which leads to the correction of delusions, than any drug. With many delusional monomaniacs psychical treatment is of far greater value than are food and drugs. If there 400 INSANITY. is any point of attack offered by these disorders when in- dependent of perverted sensations and visceral conditions, it is the logical apparatus. It is true that it is in the over- whelming majority of cases impossible to reason such patients out of a delusion, and that where this is possible, the insane fundament of the insane thoughts becomes the soil for other delusions. But occasionally external influ- ences can be brought to bear upon them in such a way as to effect a rapid cure. Leuret showed this in the days when the douche and other forcible measures were more com- monly used than now. He cured a patient, who had the delusion that he was a king, by having him douched when- ever he expressed that delusion, or responded to saluta- tions addressed to his imaginary majesty. Other lunatics would find the strongest confirmation in such a "persecu- tion." Undoubtedly prolonged restraint often leads to a growing conviction that, after all, the patient's own beliefs may be as absurd as those of other patients whose insanity he is able to appreciate, because he discovers that they ad- here as firmly to their beliefs as he has adhered to his. More than one instance of the happy effect of a recognition of the delusions entertained by others on the patient's mind is on record. It cannot be our purpose here to discuss the host of questions touching the internal administration of asylums, however intimately they may be related to the important medical problem of the moral effect of the institution on the patient. It may be expected of the writer to express his opinion, as he is about to take leave of his readers, with regard to two points which the profession, and through them the general public, may require information concern- ing — ist. The advisability of discharging lunatics on pro- bation during remissions of their disorder; 2d. The use of restraint. Remissions of insanity, rarely amounting to absolute lucidity, are very common in asylums, particularly among monomaniacs, the periodically insane, and paretic dements. There are many cases recorded of periodically insane sub- jects who voluntarily sought tha protection of the asylum whenever they felt the morbid period approaching; there are a limited number of monomaniacs whose delusions are entirely harmless, and not likely to change in this respect, who may support their families and occupy a respectable position in the community when discharged; finally, there THE PSYCHICAL TREATMENT OF THE INSANE. 4OI are a few paretic dements who cannot be regarded as non compos mentis in the remissions of that disease. All these classes are fit subjects for discharge on furlough. It should, however, be determined in some legal way that a definite responsibility is assumed by the superintendent discharging such a patient, as well as by the relatives who assume his charge. In Germany, where a furlough system and such a responsibility exist, not a single homicide or assault has occurred by a lunatic discharged under this system, and but a single theft, during five years, the insane out on furlough thus showing a far better record than the sane population. It is scarcely necessary to add that this system can be adopted only in communities in which some other factors than the political or social influence of men who turn to the asylum career, because they have failed in the general practice of their profession, are potent in de- termining the selection of medical officers of asylums. Much has been written and said about the use and abuse of mechanical restraint. That this means of controlling the insane has been pushed to an extent unwarranted by the emergencies of the case, there can be no doubt. The experience of the superintendent of the Auburn criminal lunatic asylum, who is to-day able to manage an unruly and dangerous class of patients with a minimum of restraint, while one of his predecessors not only used a maximum of restraint but also fired an occasional bullet among his charges, is a significant commentary on the correctness of the position taken some years ago by the Neurological Society with reference to this question. The concealment of restraint apparatus, particularly of that variety known as the Utica crib, when foreign alienists visit a prominent in- stitution in this State, is a confession that the apparatus and its frequent employment are, to say the least, features of which no asylum can be proud. On the other hand, it must be admitted that the agitation against restraint has over- stepped the bounds of legitimate criticism and reform. That there are some subjects who require restraint, who are better off with than without it, there can be no doubt. The demonstrative feat of a novice superintendent, who burned all his restraint apparatus as soon as he took charge of his asylum, was followed by the accumulation of black eyes, broken noses, and other minor surgical accidents, as well as by several suicides. It is with this question as with many others relating to the internal economy of asylums: 402 INSANITY. reform cannot be accomplished by watchwords and catch phrases, nor by arbitrary legislation. The proper method of improving an asylum is to develop the management and supervision of asylums in a scientific direction. Scientific zeal and integrity within asylums will prove far better guarantees of humanity to the insane than associations of dilettante and newspaper editorials. Let us hope that the scientific spirit which was breathed into American psy- chiatry by Rush and Ray, and which has been kept alive by their immediate followers, will gain that preponderance which it merits over an unworthy opposition. INDEX. Abortive monomania, 311 Abstraction, 22, 61; in paretic de- mentia, 186 Absurd beliefs, 21 Absurdity of delusions, 31 Abulia, 64, 252, 349 Accusations of hysterical lunatics, 258 Active dementia, 170; organic changes, 123, 178; phase of par- etic dementia, 190. Acts, imperative, 36 Acute hallucinatory confusion, 163; confusional insanity, 161 Acuteness of maniacs, 133, 134 Adhesion of dura to cranium, 228; of pia to cortex, no, 219 Adventitia, changes of, 106; gran- ular material in, 102, 107 Affect, 55 Affections in paretic dementia, 186 Age of paretic dements, 216; influ- ence of, on hallucinations, 53 Agitated dementia, 170; melan- cholia, 145 Agoraphobia, 36, 65 Albuminuria, 70, 211 Albutt, Clifford, on paretic demen- tia, 236 Alcohol, use of, 391 Alcoholic delirium, 254; delusions, 254; excesses in periodical insan- ity, 270; hallucinations, 253; in- sanity, 251; paretic dementia, 215; tremor, 252 Alternating consciousness, 59 Amblyopia, 202 Amenomania, 288 Amnesia, 57; diagnostic relations of, 350; in melancholic frenzy, 143; in transitory frenzy, 155; in par- etic dementia, 186 Amyl nitrite, use of, 387 Anaemia, 374; in melancholia, 144; of brain, 108 Anaesthesia, 68 Anatomical basis of mind, lOi; pe- culiarities in idiocy, 285; of mon- omania, 301, 306 Anatomy, morbid, of insanity, 92 Aneurismal changes, 107 Angry excitement, 133 Anomalies, congenital, 77; of cra- nium, 86 Anorexia, 72 Anthropophagy, 39, 43 Anxious hallucinations, 255 Apathetic dementia, 168; phase of paretic dementia, 189 Ape-fissure, 286 Aphasia, 193 Apoplectiform attacks, 193, 203, 206; albuminuria after, 211; re- covery from, 216 Apoplexy, genuine in paretic de- mentia, 206 Arachnoid, blood cysts of, 109; cal- careous plates in, 229; hemor- rhage in, 231 Arcus senilis, 174 Argyll-Robertson pupil, 208 Arrested development, states of, 275 Artefacta, 94 Artificial feeding, 394 Ascending type of paretic dementia, 185 Asylum treatment, 397 Asymmetry of skull, 87 Atavism, 278 404 INDEX. Ataxia, 73; in paretic dementia, 193, 211 Athetoid movements, 206 Atony in melancholia, 145; in in- itial period of mania, 137; in stu- porous insanity, 158; inkatatonia, 152; of intestinal tract, 72 Atrophy of brain, 103; of optic nerve, 236 Attitude of insane, 74; of alcoholic subjects, 253; orgueilleuse, 299; frozen, 72 Aura-like prodromata, 269 Austin on the pupil, 207 Automatic acts in insane, 58, 75 Axis cylinders in paretic dementia, 223 Baili.arger on cortical changes, 219; epileptic character, 259; on folie a double fortne, 1T2.\ on mono- mania, 28S Basis of mental co-ordinations, loi Baths, use of, 386 Bedsore, malignant, 213 Beliefs, absurd, 21 Bell's typhomania, 249 Benedict on hallucinations, 68 Billed on stramonium, 389 Bladder disturbances, 211 Blanching of hair, 78 Blandford on causation, 380; on monomania, 291 Blind, insanity in the, 49 Blood in insanity, 69 Bloodcysts, 109, 230 Blood-stasis. 224 Blood supply in relation to hallucin- ations, 47, 53 Blood-vessels, changes of, 106, 224, 227 232 Bones, changes of, 78 Bony plates in arachnoid, 228 Brain in insanity, 100; defects of, go, 285; cysticerci in, 112; hy- peraemia and anaemia of, loS; membranes of, 109; wasting, 164 Brierre de Boismont on extrava- gances of paretic dements, 187, 192 Bromides, use of, 385 Bromism, 339 Brown on brain wasting, 164 Brutality of paretic dements, 197 Bucknill on beliefs of imbeciles, 277; and Tuke on monomania, 290 Bulimia, 72, 140; in paretic demen- tia, 202 Calcareous plates of arachnoid, 229 Calcification of nerve-cells, 104 Calmeil on epileptic character, 259 Campagne on reasoning mania, 136 Cannabalistic tendencies, 42 Cannabis indica, uses of, 389 Cardiac disorder, 375 Cataleptic periods of katatonia, 152 Cathartics, uses of, 386 Causes, somatic, of insanity, 369; psychical, of insanity, 381; of idiocy, 276; of monomania, 301; of transitory frenzy, 157; of stu- porous insanity, 159; of delirium grave, 247 ; of primary deteriora- tion, 164 Cavities of the neuroglia, 106 Cerebral tissues, changes in, loi Change, sudden, of delusions in pa- retic dementia, 199 Character, epileptic, 260; in circu- lar insanity, 274; in periodical in- sanity, 269; in hysterical insanity, 257; change of, 178; in paretic dementia, 185; maniacal, 136 Chloral, uses of, 385 Chronic insanity, 373 Choreomania. 373 Chronic alcoholic insanity, 251; con- fusional insanity, 170; delusional insanity, 283; hysterical insanity, 256; mania, 170 Circular insanity, 271 Civilization, influence of, on paretic dementia, 182 Clarke, Lockhart, on cystic degener- ation, 219 Classification of insanity, 113 Claustrophobia, 36 Climacteric insanity, 122 Clivus, anomalies of in pyromania, 87 Complicating insanities, 121, 124, 129 Complication of one form of insan- ity by another, 128; of mono- mania, 319, 345 INDEX. 405 Concealed delusions, 323; insanity, 352 Conceptions, imperative, 35 Concussion, 370 Confession of imaginary crimes, 141 Confusion of ideas, 162; acute hal- lucinatory. 163 Confusional insanity, primary, 161; secondary, 170; morbid changes in, 102 Congenital anomalies, 77; mono- mania, 30S Congestive attacks of paretic de- mentia, 207 Conium, uses of, 3S4 Connecting links of degenerative series, 88 Connection between lesions and symptoms. 113 Consciousness, disturbances of, 57; alternating, 59; double, 59; of impending loss of reason, 61 Convalescence of mania, 139 Convallaria. uses of, 388 Convulsions, 351 Convolutions, atrophy of, 103; in paretic dementia, 218 Coprostasis, effects of. 112 Corpus callosum in imbeciles, 286 Corrugation of brows in paretic de- mentia. 210; in monomania, 339 Cortex, changes in, loi; in paretic dementia, 218; adhesion of pia to, 219, 231; cystic degeneration of, 219; in imbecility, 285 Crampi in alcoholism, 252 Crania progenia, 87, 282 Cranial diploe in paretic dementia, 22S Cranium, changes of, in insanity,86 Cretenism. 282 Crib of Utica, 401 Criminal acts of insane, 398; of paretic dements. 187 Cyclothymia, 271 Cystic degeneration of cortex, 219 Cysticerci, 112 Cystitis in paretic dementia, 211 Dagonet on morbid anatomy, 102 Dangers of insanity. 39S Death in melancholia, 148; in pare- tic dementia, 193 Decubitus, malignant, 78, 213 Defects in idiotic brain, 90 Definition of circular insanity, 271; of delusion, 24, 29; of dipsoma- nia, 271; of hallucination, 43; of illusion, 44; of insanity, 17, 19; of katatonia. 149; of mania, 131; of melancholia, 141; of monoma- nia, 301; of paretic dementia, 241; of periodical insanity, 267; of primary confusional insanity, 161; of primary deterioration, 163; of pubescent insanity, 175; of senile dementia, 171; of stupo- rous insanity, 158 Degeneration in monomania, 293 Degenerative changes in brain, 102; series of forms of insanity, 88 Deglutition, impairment of, 211 Deliberation of the insane, 64 Deli re dcs actes, 270 Delirium, 341; acutum. 247; of epi- leptic insanity, 264; grave, 80, 247; of mania, 133; of melan- cholic frenzy, 143; of monoma- nia, 296; of paretic dementia, 192, 203; tremens, 251; hysteri- cal, 217 Delusion, definition of, 24 Delusional insanity, 288; monoma- nia, 312 Delusions of alcoholic insanity 254; of confusional insanity 162; diagnostic bearing of, 340, 348; in delirium grave, 248; de tection of, 327; depressive, 28 141; erotic, 27, 300; expansive 27, 298; genuine, 25; of grand eur, 32, 248; hypochondriacal 26; of mania, 138; of marital infi- delity, 33; mechanism of, 28; of melancholia, 141; modifying in- fluence of external circumstances on, 34; of visceral impressions on, 33; of paretic dementia, 195, 199; persecutory, 26; religious, 27, 304; rudimentary, 36; of se- nile dementia, 173; spurious, 25; systematized, 25, 288; unsys- tematized, 25, 31, Dementia agitated, 170; brain in, 108; epileptic. 259; frequency of, 168; nerve cells in, 104; neurog- lia in, 106; paretic. 178; para- 4o6 INDEX. lytic, 179; passive, 168; senile, 171; syphililic, 243; terminal, 166; trophic changes in, 171; varieties of, 119, 120 Depressed states, differential diag- nosis of, 330 Depressive delusions, 141; period of mania, 137 Descending type of paretic demen- tia, 214 Destruction of nerve-cells, 105, 223 Detection of simulation. 364 Deterioration, primary, 163; secon- dary, 166; of nerve cell proto- plasm, 222 Development, states of, arrested, 275 Diagnosis of insanity, 320, 330; of circular insanity, 273 Diarrhoea, 72 Diet of insane, 393 Digitalis, uses of, 388 Differential diagnosis of the vari- ous forms, 330 Diminutives, use of, in katatonia, 152 Diploe in paretic dementia, 228 Diplopia, 240 Dipsomania, 37, 271 Discoloration of cortex, 219 Disseminated sclerosis, 223 Diurnal change of symptoms in melancholia, 149 Double consciousness, 59, 163 Down, on ethnic types in idiocy, 279 Dreams causing delusions, 33; in primary deterioration, 164 Drunkenness, influence of, on pro- geny, 83 Dura mater, inflammation of, 109, 228 Duration of mania, 138; of melan- cholia, 147; of paretic dementia, 216 Dysuria spastica, 72 Ecstatic states, 258 Effluvium in mania, 72 Ego, 60 Egotism in senile dementia, 172; in monomania, 309 Electricity, uses of, 393 Electro-muscular reactions, 67 Emminghaus on exophthalmic goi- tre, 376 Emotional disturbance, 56; insan- ity, 551 disturbance in mania, 132; in melancholia, 140; tremor, 209; diagnostic importance of, 349 Emotions in imbeciles, 281 Endyma, changes of, 220 Engelhorn on transitory frenzy, 156 Ependyma layer in imbecility, 285 Epilepsy, relation of, to periodical insanity, 91; in imbeciles, 282; Epileptic insanity, 258: dementia, 259; morbid anatomy of, 99, 102, 107; chronic, 261; intervallary, 261; handwriting in, 266 Epileptiform attacks in paretic de- mentia, 193, 203, 205; pathology of, 227 Episodical attacks of paretic de- mentia, 203; pathology of, 237; delirium in monomania, 296 Epithelial granulations of pia, 109 Equivalent, psychical epileptic, 259 Erotic delusions, 27; monomania, 317 Erotomania, 27, 300 Erlenmeyer on syphilitic hypo- chondriasis, 243 Errors of pathologists, 93; of Uti- ca school, 95; of sane as differ- ing from delusions, 28 Esquirol on epileptic dementia, 259; on monomania, 287; on morbid anatomy, 96 Etat criliW, 107 Ethnic types in idiots, 278 Etiology of insanity, 369, 381; of paretic dementia, 240 Etiological forms, 115, 370-379 Examination of the insane, 320 Excesses of paretic dements, 190 Exhaustion, maniacal, 139 Exhileration of paretic dements, 192 Expenditures, extravagant, 192 Explosion of paretic dementia, 190 Exposure, indecent, 188 Expression of the insane, 74, 322 Extravagant projects, ig8 Facial appearance of alcoholic sub- jects, 253 INDEX. 407 Factors determining delusions, 31 Faithful memory of insane, 58 Falret on epileptic insanity, 260; in folie circulaire, 271 Fatty changes of nerve-cells, 105 Feeble-mindedness, 275 Females, paretic dementia in, 196, 217; periodical insanity in, 376 Fever, secondary, of syphilis; in- sanity in, 244 Fibrillary change of neuroglia, 105, 106; tremor, 337 Flemming on recovery from pa- retic dementia, 216 Flight of ideas in mania, 132 Fluxionary states in insanity, 107 Folie a double forme, 272; a deux, 367; circulaire, 271; communi- que'e, 367; du doiite, 308, 311; raissonante, 65 Fournier on pseudoparalyses, 246 Foville on cranial deformity, 87; on transitory frenzy, 155 Free nuclear bodies, proliferation of, 225 Frenzy, melancholic, 142; transi- tory, 154; melancholic, 143 Frequency of mania, 13S; of mel- ancholia, 148; of senile demen- tia, 175; of pubescent insanity, 177; of paretic dementia, 180 Fright, precordial, in melancholia, 143 Frozen attitude, 72 Furloughs for insane, 401 Furor, 135: maniacorum, 135; of paretic dementia, 192, 204; transi- tory, 55 Fiirstner on cortical lesions in pa- retic dementia, 243 Fury, pathological, 55, Gait in paretic dementia, 210 Galloping paretic dementia, 203 Ganglionic bodies of cortex, changes in, 104; in paretic dementia, 221 Gangrene, pulmonary, 80, 213 Gauster on recovery in paretic de- mentia, 216 Generosity of paretic dements, 194 Goitre exophthalmic, 376 Gouty insanity, 374 Grand mat intellectuel, 260 Grandeur, delusions of, 336 Granular matter in adventitia, 102, 107; wasting, 222 Granulations, epithelial, of pia,l09; of ventricular endyma, 220 Gray, L. C., on temperature, 71 Griesinger on Griibelsucht, 36, 58, 311; on primary and secondary forms, 289 Ground-glass appearance, 221 Grossemuahnsimi, 295 Griibelsucht, 36, 65, 311 Gruyere cheese appearance, 219 Giintz on senile dementia, 174 Grave delirium, 247 Gyri of idiot's brain, 278 H.'EMATOMA of ear, 79; of dura, 230 Haematuria in paretic dementia, 211 Hallucinations, 43; definition of, 43; visual, 50; auditory, 51 ; gus- tatory and olfactory, 53; unilat- eral, 52; in paretic dementia, 200; in katatonia, 152; in mel- ancholia, 142; in mania, 134; in monomania, 313, 316, 318; in al- coholic insanity, 253; differential diagnostic relations of, 349; in the sane, 21 Hallucinatory mania, 134; confu- sion, 163 Hammond, on mysophobia, 36; on extravagances in paretic demen- tia, 192, 203; on Kalmuck idiocy, 278 Handwriting of insane, 76; in pa- retic dementia, 210; in monoma- nia, 76; in epileptic insanity, 266 Headache in katatonia, 152; in pa- retic dementia, 338 Head injuries, 370 Head sensations in melancholia, 144; in confusional insanity, 163 Heart disease in insanity, 375 Hebephrenia, 176 Hecker on hebephrenia, 176 Haemorrhage of brain in paretic dementia, 206 Haemorrhagic pachymeningitis ,229 Hereditary transmission, 275; mo- dus of, 83; transformations in course of, 91 Herpetic eruptions, 78 His, perivascular space of, 106, 227 4o8 INDEX. Homicidal impulse, 37; in melan- cholia. 146; monomania, 36 Howard on temperature of insane, 69, 71 Hughes on simulation, 358 Huguenin on durhaematoma, 229 Hyaline thrombi, 527 Hyoscyamia, uses of, 389 Hypersemia of optic disc, 67, 236, of brain, 108; of cortex, 239; in delirium grave, 250 Hyperaethesia, 68; in alcoholic in- sanity, 212 Hyperalgesia, 68 Hyperbulia, 64, 349 Hypochondriacal delusions in mel- ancholia, 141; in monomania, 316 Hypochondriasis, syphilitic, 243 Hypocrisy in hebephrenia, 176 Hypomania, 136; like condition in paretic dementia, 203 Hysterical insanity, 256 Identity, changed sense of, 60; in confusional insanity, 162; in mania, 134 Idiocy, 275; brain defects in, 90; gyri, 278; varieties of, 276; ata- visms in, 278; ethnic types of, 278; instincts in, 279 Illusions, 43; definition of, 44; of sight, 50; of hearing, 51; of smell and taste, 53; of identity, 50; in paretic dementia, 200; de- pendence of on tinnitus aurium, 53 Imbecility, 275, 280; moral, 281; partial, 281; anatomical defects in, 90, 285 Imitative tendencies of idiots, 280 Imperative conceptions and acts, 35. 36, 349; movements, 75 Impression, maternal, influence of on progeny, 84 Impulse, homicidal, 37; morbid, 36, 270 Inconsistency of unsystematized delusions, 33; in hebephrenia, 176; in paretic dementia, 195 Increased frequency of paretic de- mentia, 183 Indecent exposure, 187 Inebriety, 252 Inequality of pupils, 207, 336 Inflammatory process in paretic de- mentia, 218, 238 Influence of insanity on disease, 80 Inhibition, logical, 29; in mania, 132; in melancholia, 141 Initial stage of mania, 137; of mel- ancholia, 147; of katatonia, 149; of paretic dementia 184 Injuries of head, 369 Insane attitude, 74; expression, 74, 321; manner, 74, 321 Insanity, definition of, 17, 19; cir- cular, 271; delusional, 288; dis- simulated, 353; intellectual, 293; morbid anatomy of, 92; moral, 2S1; primary, 289; secondary, 289; simulated, 352; somatic signs of, 81; trophic disturbanc- es of, 77 Insanity of pubescence, 175; pro- pensities of, 176; frequency of, 177 Insolation, 369, 371 Insomnia in primary deterioration, 164; treatment of, 385 Instincts in idiots, 279 Intellectual labor as a cause of in- sanity, 382. Intellectual insanity, 293 Intensification of neurotic vices in transmission, 85 Intervals of paretic dementia, 193 Intervallary epileptic insanity, 261 Intestinal tract in insanity, 71 Interstitial encephalitis, 221 Ireland on varieties of idiocy, 276 Iron, uses of, 392 Irritability in paretic dementia, 188, 189 Isthmus affections in paretic de- mentia, 241 Jacobi of Germany, somatic the- ory of, 71 Jessen on delirium grave, 249 Johnson, case of, 75 Jolly on hallucinations, 68 Kahlbaum on katatonia. 149 Kalmuck idiocy, 278, 358 Katatonia, 149; hallucinations in, 152; prognosis and frequency INDEX. 409 of, 153; morbid anatomy of, 98, 102, 230 Kiernan on othaematoma, 79; on katatonia, 149; on transitory frenzy, 155, 156, 157; on athetoid movements in paretic dementia, 206; on trophic changes, 212, 232; on simulation, 358; on use of ergot, 387 Kinking of blood-vessels, 107, 226 Kirchhoff on original monomania, 307 Kirn on pupillary spasm, 75 Kleptomania, 37, 270 Koster on periodical insanity, 268 Krafft-Ebing on stigmata, 89; on degenerative forms, 116; on morbid anatomy, 97; on classi- fication, 117; on hysterical insan- ity, 257 LacuNv*; of memory in paretic de- mentia, 192; in syphilitic demen- tia, 244 Lamination of cortex, obliteration of, lOI Lasegue and Garel, on crania of epileptics, 87 Le Grand du Saulle on stigmata, 89 ; on folie du doute, 311 Legal aims of a definition of insan- ity, 19 Legal insanity, 23 Leptomeningitis, 231 Lesbian love, 42 Lettervvriting tendency, 210 Leucin precipitates, manufactured at Utica, 95 Leuret, illusion of, 53 Lymphatic flow, retardation of, 102, 106, 108 Lypemania, 287 Locomotion disturbances, 350 Locomotor ataxia in paretic de- mentia, 210; its analysis, 240 Logical inhibition, 29 Lubimoff on paretic dementia, 223 Lucid intervals in paretic dementia, 193; in mania, 139 Magnetic illusions, 54; in pare- tic dementia, 200 Malarial insanity, 374 Maldevelopment after organic af- fections, 82 Malignant decubitus, 213 Mania, defiiition of, 131; delusions in, 134; depressive stage of, 137; duration of, 138; errabunda, 181; exhaustion in, 139; chronic, 288; frequency of, 138; in puerpero, 133. 377; identity, change of sense of, 134; hallucinations in, 134; hallucinatory, 134; gravis, 247; morbid anatomy of, 97; mel- ancholic, 137; periodical, 269; prognosis of, 138; recurrent, 140; transitory, 55, 154; typical, 131 Maniacal excitement, 120; in kata- tonia, 152; fury, 135; furor in paretic dementia, 203; morbid anatomy of, 227 Manie grave, 123; raissonante, 65; systematisee, 288 Manner, insane, 74 Mannerisms of insane writings, 77 Marasmus of nerve-tissue, 172 Marce on monomania, 288 Marital infidelity, delusions of, 33, 254 Marks of insane resembling bruises, 80 Masturbation, 378; in hebephrenia, 176, 177 Masturbatory insanity, 54, 379 Maternal impressions, 84; prepon- derance of influence of, 82 Maudsley on classification, 114 Mechanism of hallucinations, 44 Medicinal treatment of insanity, 384; means for detecting simula- tion, 368 Medico- Psychological Association, classification proposed by com- mittee of, 114 Megalomania, 200, 295 Melancholia agitata, 144; anaemia in, 114; attonita, 145; cum stu- pore, 145; delusions in, 31, 141; definition, 140; duration, 147; ex lactatio, 377; from masturba- tion, 379; frenzy in, 142; fre- quency of, 147; hallucinations in, 142; head-symptoms in, 144; homicide in, 146; in puerpero, 378; mild, 146; maniacal, 142; morbid anatomy of, 98; progno- 4IO INDEX. sis of, 148, 149; periodical, 271; precordial fright in, 143; pulse in, 143; sine delirio, 69, 146, 148; suicide in, 146; self-mutilation in, 142; weight in, 144; without delusions, 146 Memory, disturbances of, 57; in melancholia and mania, 140; in imbecility, 281; in dementia, 165; in paretic dementia, 192 Mendacity in paretic dementia, 198; 215 Mendel on mania, 97; on hypoma- nia, 136; on hallucinatory mania, 134; on paretic dementia, 231; on haematoma, 230 Meningitis, 370; from over-study, 248. Meningo-myelitis, 232 Menstrual insanity, 267, 376 Metallic poisons, 374 Meynert, on hallucinations, 46; on melancholia, 98; on brain-weight in insanity, 109; on paretic de- mentia, 223 Mickle on paretic dementia, 197, 199, 201 Microgyria, 286 Micromania, 200 Mild melancholia, 146 Miliary aneurisms, 107; sclerosis, 95 Milky opacity of leptomeninges, 109; 231 Mind, anatomical basis of, loi Miserly inclinations in paretic de- mentia 190; in senile dementia, 172 Monomania, abortive, 311; abuse of term, 287; brain-defects in, 90; congenital, 308; definition of, 300; delusional, 312; diagnosis of, 335; erotic, 317; handwriting in, 76; homicidal, 36; history of, 286; masturbatory 380; morbid an- atomy of, 99, no; persecutory, 299,314; prognosis of, 31S; queru- lous, 315; reasoning, 309; re- ligious, 300; relation of, to im- becility, 88,281; secondary, 170; sine delirio, 309 Alonomanie gaie, 288; triste, 288; vaniteuse, 295 Moos on hallucinations of hearing, 53 Moral insanity, 56, 281; imbecility, 56, 281; perversion, 56; deteri- oration in paretic dementia, 190 Morbid anatomy of insanity, 92; of paretic dementia, 218; of de- lirium grave, 250; impulses, 36, 270; propensities. 35, 38 Morel on stigmata of heredity, 89; on classification, 115; on mon- omania, 288 Moria, 341; post-epileptic, 269 Motor disturbances, 73; in katat- onia, 150; in paretic dementia, 191, 242, 209; in imbeciles, 282 Motor excitement in mania, 135; as a factor in differential diagno- sis, 335 Alouvetnents en viandge, 206 Movements, imperative, 75; rhyth- mical, 75 Multiple sclerosis, 214 Muscular coat of arteries in paretic dementia, 225 Musky odor of idiots, 73 Mutism, 255, 337 Mysophobia, 36, 65 NASSEon pupil in paretic dementia, 208 Necrobiosis of ganglionic bodies, 221 Necrophilism, 43 Negative pathology of mania, 97 Nerve-cells, atrophy of, 103, 104, 221 ; destruction of, 103; pigmen- tation of, 102; in acute delirium, 104, 250; in mania and melan- cholia, 104 Neumann on paretic dementia in females, 217 Neuroglia, changes in, 105; nuclei of, 105; in paretic dementia, 223 Neuroses, dependence of insanity on, 124 Neurosis, traumatic, 371; hysteri- cal, 256; epileptic, 258; alcoholic, 251 New formation of vascular chan- nels, 225 Nitrite of amyl, uses of, 387 Nuclear bodies of neuroglia, 105 in imbeciles, 286; proliferation of, in adventitia, 106 INDEX. 411 Nutritive disturbances in insanity, 104 Nymphomania, 27, 39, 380 Objective surroundings, recogni- tion of, by the insane, 62 Oblongata, changes of, in paretic dementia, 223 Obscenity of maniacs, 132 Occipital headache in katatonia, 152; lobe in paretic dementia, 202, 243; in imbeciles, 286 Oddities of behavior in paretic de- dementia, 215; of speech in in- sane, 351 Oophorectomy, 376 Opium, uses of , 388; insanity from, 254, 255, 271 Optic papilla in paretic dementia, 235 Organic changes in alcoholic in- sanity, 128, 251; in senile de- mentia, 128 Originiire Verriicktheit, 301 Osteophytes of sella turcica, 87 Othaematomata, 78 Outbreak of mania, 137; of deliri- um grave, 248; of periodical mania, 269 Over-study, effects of, 248 Pacchionian bodies, 109 Pachymeningitis, 229; hemorrha- gica, 229 Papilla optic, in paretic dementia, 235 Paraesthesia, 68 Paralucid intervals of paretic de- mentia, 193 Parental influence, 82 Paresis, 73 Paretic dementia, 178; abstraction in, 186; affections changed in, 186; age of subjects of, 216; alcoholic form, 215; amblyopia in, 202; apathy in, 189; aphasia in, 193; apoplectiform attacks in, 193, 203, 206; ataxia in, 191, 193; bladder disturbance in, 211; bru- tality in, 197; bulimia, 202; causes of, 240; change in character of delusions of, 199 ; character, peculiarities in, 185; complicat- ing other forms of insanity, 338; course of, 184; decubitus in, 213; deglutition impaired in, 211; de- lusions of, 192, 195, 196, 197; diagnosis of, 338; duration of, 216; epileptiform attacks in, 193, 203, 205; episodial attacks of, 203; exhilaration in, 192, 194; explo- sion of, 190; extravagant expendi- tures in, 192; female cases of, 196,217; frequency of, 180; furor in, 204; gait in, 210; galloping form of, 203; generosity in, 194; hallucinations in, 200; handwrit- ing in, 209, 210; hemorrhage in, 206; hypochondriacal, phases of, 200; initial period of, 184; irrita- bility in, 189; isthmus changes in, 241; letter-writing tendency in, 210; lucid intervals of, 193; maniacal attacks in, 203; men- dacity in, 198; miserliness in, 190; morbid anatomy of, 99, 100, 2x8; moral deterioration in, 190; motor disturbance of, 209; neu- roglia in, 223; oblongata, changes in, 223; optic papilla in, 235; perivascular spaces in, 107; pia in, 231; pons, changes in, 21S, 223; physical signs of, 190; prog- nosis of, 215; prodromal period of, 184; projects in, 192, 198; ptosis in, 209; pulse in, 212; pyonephritis in, 211; relation of lesions to symptoms of, 236, 243; relation of physical and mental signs, 178, 180; remissions of, 193, 214; sclerosis in, 214; sens- ory disturbances in, 201, 211; septic complications of, 213; speech disordered in, 209; spider- shaped cells in, 223; spinal cord in, 231; spinal symptoms of, 240; suffocation in, 210; stages of, 1S4; temperature in, 212; tremor in, 209; trophic disturbances of, 193, 212; varieties of, 214; vaso- motor disturbances in, 212; white substance, changes of, in, 223 Partial insanity, 90, 287; punish- ability, 52 Parturient state, 378 Passive dementia, 170 Pathological fury, 55: results of insane excitement, no, rii 412 INDEX. Pathos in katatonia, 150 Pellagrous insanity, 124, 125 Pelman on pupil in paretic demen- tia, 208 Pemphigus in delirium grave, 250 Penuriousness in senile dementia, 172 Periganglionic spaces, 106; in par- etic dementia, 220 Periodical insanity, lesions of, 107; relation of, to epilepsy, 91 ; defi- nition of, 267; mania, 269; melan- cholia, 271; morbid impulses 270; prognosis of, 274 Peritonitis, influence of, on de- lusions, 33, 34 Perivascular spaces, 106, 220 Persecutory delusions, 26; mono- mania, 318 Perversion, moral, 56; sexual, 39 Petit vial intellectuel, 260 Pfleger on brain-weight, 109 Phosphates, loss of, in insanity, 69 Phosphorus, uses of, 69, 392 Photopsia in relation to hallucina- tions, 255 Phrenitis, 247 Phthisical insanity, 375 Physical signs of insanity, 65; of senile dementia, 174; of paretic dementia, 207; of alcoholic in- sanity, Pia, changes of, in insanity, 109, no; in paretic dementia, 231 Pigmentation of nerve-cells, 102, 104, 222 Plagiarism committed by the in- sane, 27 Planning of insane acts, 64 Plates, bony, in membranes of brain, 22S Ponicare and Bonnet, theory of, as to paretic dementia, 235 Pons, changes in paretic dementia, Popular idea of insanity, 359 Porencephaly, 384 Post-epileptic insanity, 260; stupor, 260; moria, 261 Post-febrile insanity, 373 Post-mortem changes in the brain, 95 Precordial fright, 143 Predisposition to insanity, 382; signs of, 81 Pre-epileptic insanity, 261 Pregnancy, morbid propensities in, 38; insanity in, Preponderance of maternal in- fluence in heredity, 82 Primary confusional insanity, i6i; prognosis of, 163 Primary dementia, 160, 177, 379; insanity, 122, 289; mental deteri- oration, 163 Primordial-Delirieti, 292 Principles of classification, 118, 119 Prisoners, insanity in, 49 Prognosis in alcoholic insanity, 256; in hebephrenia, 177; in hys- terical insanity, 258; influence of haematoma on, 79; in katatonia, 153; in mania, 138; in melan- cholia, 148 ; in masturbatory cases, 379; in monomania, 318; in peri- odical insanity, 279; in paretic dementia, 215; in primary confu- sional insanity, 163; in senile de- mentia, 174; in stuporous insan- ity, 160. Progressive Paralyse, 179 Progressive Paresis, 180 Projects of the insane, 27 Propensities, morbid, 35, 38 Pseudo-emotional states in paretic dementia, 209 Pseudo-monomania, 288 Pseiidoparalysie g^n^rale, 246 Psychical degenerative states, 321; causes of insanity, 381; treat- ment, 397 Psychoneuroses, 121 Ptosis in paretic dementia, 209; in neurotic subjects, 339 Puerperal state, insanity of, 377 Pulse in melancholia, 143; in pare- tic dementia, 212 Pulsus tardus, 70 Punishability of the insane, 52 Pupil in insanity, 75; in paretic de- mentia; Argyll-Robertson, 208; diagnostic importance of, 336 Pure insanity, forms of, 121 Pyonephritis in paretic dementia, 211 Pyromania, 37; cranial deformities in, 87 Qiierulanten- Wahnsinv, 315 INDEX. 413 Querulous monomania, 315 Quiet type of paretic dementia, 2 14, 217 Race, question of, in relation to paretic dementia, 181 Radiant heat as a cause of insan- ity. 371 Raptus melancholicus, 143 Rarefication of neuroglia, 223 Reactions, electro-muscular, 67 Reasoning of maniacs, 133; mono- mania, 309 Recurrent mania, 140 Reflexes in stuporous insanity, 159 Refusal of food, 394 Reich on transitory frenzy, 157 Reinhard on septic complications of paretic dementia, 213 Relation of skull-shape to insanity, 86, 87 Religious delusions, 27 ; mono- mania, 304 Remissions, 400; of paretic demen- tia, 214 Restraint, 401 Retardation of lymph-outflow from cortex, 102, 106, 108 Retina in insanity, 66 Retinal after-image, analogy of, to memory, 44 Reversion of idiots to apes, horses, sheep and other animals, claim of. 276, 277 Rheumatic insanity, 374; causation of paretic dementia, 215 Rhythmical movements in insane, 75; in delirium grave, 249; in katatonia, 151 Richarz on parental influence, 82 Ripping on insanity in puerpero, 377; on syphilitic psychoses, 245 Rush on moral imbecility, 56; on nomenclature, 288 Saliva, dribbling of, 159 Samt on post epileptic insanity, 260 Sander on origindre Ve7'riicktheit,2,o?> Sankey on vascular kinking, 226; on monomania, 291 Satyriasis, 39, 173 Schopenhaur, case of, 92 Schiile on delirium grave, 247; on frequency of paretic dementia in females; on hyoscyamime, 389; on morbid anatomy of mono- mania, 99; on recovery of paretic dementia, 216 Sclerosis of cortex, 219; of oblon- gata, 223; of cord, 232; cerebro- spinal, 216, 223, 240; miliary, 95; of optic papilla, 236 Secondary fever of syphilis, insan- ity with, 243; deterioration, 166; insanity, 122, 289; insanity with confusion of ideas, 170; partial insanity, 170 Self-consciousness, 60 Self-mutilation in melancholia, 145 Sella turcica in pyromania, 87 Senile dementia, 171; anatomical changes in, 106; definition of, 171; delusions in, 173; hyperaes- thesia in, 174; frequency of, 175; memory in, 172, 173; insanity, 171 Sensibility, disturbances of, 68; in paretic dementia, 211 Sentiments distinct from emotions, 55 Sex, relation of, to mania, 13S; to melancholia, 148; to paretic de- mentia, 217; to periodical insan- ity, 274 Sexual ideas in paretic dementia, 196; mutilation, delusion of, 254; perversion, 39, 308; sensations in hysterical insanity and mono- mania, 258, 312 Shepard's definition of insanity, 221 Shrinkage of pyramidal bodies of cortex, 221 Simon on paretic dementia, 191, 197, 202 Simulation, 352; by hebephreniacs, 176; by hysterical patients, 257; by masturbatory lunatics, 379; by the insane, 357 Sitophobia, 394 Skae's classification, 115 Skin in insanity, 72, 78, 363 Skull, condition of, in paretic de- mentia, 228; deformity of, 86; asymmetry of, 87, 305 Snell on syphilitic paretic demen- tia, 244; on Vcryiicktheit, 244 Somatic etiology of insanity, 369. 414 INDEX. signs of insanity, 8i; disturb- ances in alcoholism. 253 Special senses, illusions and hallu- cinations of, 50 Speech in insanity, 76; disturb- ances, 350; in paretic dementia, 191, 209; in idiots, 280 Spider-shaped cells in paretic de- mentia, 223 Spinal cord in paretic dementia, 231-235; lymph-spaces of, 220; type of paretic dementia. 185 Sphygmograph, revelations of, 70, 213 Stages of paretic dementia, 1S4 Stasis, thrombic, 229, 239 States of arrested development, 275; epileptic mental, 259 Stearns on electrical basis of mind, 393 Stigmata of heredity, 86, 89, 279, 350 Stomach pump, use of, 395 Stramonium, use of. 389 Strychnia, use of, 389 Stuporous insanity, 120; definition, 1 58; prognosis of, 160 Suffocation in paretic dementia, 211 Suicidal impulse, 37 Suicide in melancholia, 141, 146 Sunuitnrische Erinneriiiig, 59 Sutherland on the blood in insan- ity, 69 Symptomalogy of the various forms of insanity, 131-329 Syphilitic dementia, 244; hypo- chondriasis, 243 Systematized delusions, 25, 295, 314 T.^^DiUM vitae in paretic dementia. 179 Taint, constitutional, signs of, 81 Temperature in insanity, 71; in paretic dementia, 212; in deie- rium grave. 249 Terminal deterioration, 166 ; de- mentia, 169 Tetanic condition of muscles in in- sanity, 74 Theatrical behavior in katatonia, 150. 151 Thefts committed by paretic de- ments, 187 Theomania, 300 Thrombic stasis, 227 Thunderstruck melancholia, 145 Thyroid gland in cretiiiism, 284 Touch-sense, disturbances of, in paretic dementia, 201; transfor- mation of psychosis in hereditary transmission, gi. 275; of delu- sions in monomania, 316 Transition of mania to melancholia in circular insanity, 274 Transitory frenzy, 154, 377; furor, 55; mania, 55, 154 Transmission of hereditary vices, modus of, 83, 84, 275; intensifica- tion of neurotic, vice in, 85, 86 Traumatic insanity, 370 Tremor, 351; ataxic, 209; emotion- al, 209; paretic, 209; alcoholic, 252 Treviranus on brain in sleep, 47 Tristimania, 288 Trophic disturbances in insanity, 77. 350; in paretic dementia, 193, 212; in delirium grave, 249 Tuke, D. Hack, on classification, 115; on artificial feeding, 395 Turnbull on paretic dementia in the young, 216 Typhomania, 247 Ullrich, case of, 40 Undue influence in senile demen- tia, 173 Unilateral hallucinations, 52 Unsystematized delusions, 25, 31, 195. 197 Urine in insanity, 69; in paretic de- mentia, 212 Utica crib, 401; spurious pathol- ogy of school at, 95, 96 Van der Kolk on sympathetic in- sanity, 71 Varieties of idiocy, 276; of paretic dementia, 214; of mania, 136; of melancholia, 144; of monomania, 295, 314; of periodical insanity, 269 Vascular walls, changes of, 106; strain, effects of, 107, no Vaso motor condition in paretic de- mentia, 212, 237 Venesection, indications for, 386 INDEX. 415 Ventricles in paretic dementia, 220; granulations of, 220 Verbigeration in katatonia, 151 Verriicktheit primdre, 289; origu ndre, 301 Vesicular degeneration^of cord, 233 Violence as a cause of othaema- toma, 78 Virchow on durhsematoma, 229 Visceral sensations as basis of illu- sions, 54; lesions in insane, iii, 112 Visions, 341; in paretic dementia, 236; monomania Vogt on idiots, 275 Voisin on classification, 116, on anosmia in paretic dementia, igo; on pulse in paretic dementia, 212 Vulgarity of paretic dements, 190 Wahnsinn, 289 Wasting of brain, 164; in paretic dementia, 218 Weakness, mental, in its differen- tial diagnostic relations, 350 Weight of brain, in insanity, 108; of body in circular insanity, 273; in melancholia, 144 Westphal on imperative concep- tions, 40; on confusional insan- ity, 163 White substance of brain, changes in, 103, 223 Will, disturbances of, 64; in alco- holic insanity, 252; in paretic de- mentia, iSS Winslow on double consciousness, 59 Wolff on pulsus tardus, 70 Word-stoppage in paretic dementia, 207 Wundt on normal temperament, 189 Yandell on epidemic insanity, 373 Young, paretic demetia in the, 216 Zacchias on recognition of insan- ity by the insane, 62; on detec- tion of simulation, 364 v UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. ■^^yy/iiS 137a BioME&*PR-2A^8 JUNO 7 ;'p 'BIOM»1V|'/ft^S'l'l98b Biomed Ar K i Uwm»^ APR 1 19(11 BiMm A%R 1 FEB 4 981 41981 Form L9-40m-5,'67(H2161s8)4939