NLM DDS5fiEb7  D
ARMY MEDICAL LIBRARY
FOUNDED 1836
U3BB*
4JVfl£a
U.S. NATIONAL
      LIBRARY
            OF
,s;-
ji.
fe*
NLM005582670 
       RETURN TO
NATIONAL LIBRARY OF MEDICINE
  BEFORE LAST DATE SHOWN
VI
---E>
JUL  31  1985 
-•fv;
 

 
1 
MENTAL DISEASES 
 
MENTAL  DISEASES.
   A SYNOPSIS OF TWELVE LECTURES




DELIVERED AT THE HOSPITAL FOR THE INSANE,

  TORONTO, TO THE GRADUATING MEDICAL

                 CLASSES,



                    BY



   DANIEL CLARK,  M.D.,


Medical Superintendent; Extra Mural Professor of Medical Psychology in the
  University of Toronto, Canada; ex-President of the Medical Council and of the
  College of Physicians and Surgeons of the Province of Ontario; ex-President
  of the American Medico-Psychological Association ; Vice-President of the New
  York Medico-Legal Society, etc., etc., etc.
               TORONTO:

       WILLIAM  BRIGGS,

            WESLEY BUILDINGS.

Montreal: C. W. Coates.     Halifax: S. F. Huestis, 
 
PREFACE.
Thts manual is simply an introduction to the study
of Mental Diseases.
  It is intended for the  senior medical student and
the busy physician, who  may have neither time nor
opportunity to study the higher  and more intricate
branches of psycho-physics.
  The  Author has  attempted  to  be as practical as
possible, and has left out  matters of secondary impor-
tance to the profession.   It is to be hoped this hand-
book will accomplish what the writer had in view in
these respects.
  Once for all, the Author acknowledges his indebt-
edness  to such eminent men as Bucknill, Tuke, Gower,
Hughlings   Jackson,  Gray,  Bevan  Lewis,   Regis,
Mercier, Savage, Maudsley, Clouston, etc., etc.
                                          D. C,
  1895,
3 %66 ?2- 
\
 V
 \
i 
CONTENTS.
chapter                                             page
       I.   The Brain................................     9
      II.   Mind....................................    21
     III.   Brain Pathology..........................    27
     IV.   Insanity—What  it is Not...................    37
      V.   A Delusion..............................    47
     VI.   The Manias..............................    56
     VII.   Dementia................................    69
    VIII.   General Progressive  Paresis...............    76
      IX.   Puerperal Insanity........................    87
      X.   Circular Insanity.............■.........r ■ ■    94
      XI.   Melancholia.............................   1°6
     XII.  Moral Insanity...............'......•.....   x22
    XIII.   Epilepsy of  the  Insane....................   13°
    XIV.   Syphilitic Insanity........................   145
     XV.  Onanic Insanity............:..............   149
    XVI.  Paranoia...................-..............   159
    XVII.  Phthisical Insanity........................   167
   XVIII.  General Bodily  Conditions.................  177
    XIX,  Amentia. r.......,........................   182 
viii
CONTENTS.
 CHAPTER                                              PAGE
     XX.  Mind Stress..............................   188
    XXI.  Notes on uie Condition of Patients on Exami-
               nation ................................   198
   XXII.  Treatment of the Various  forms of  Insanity.   202
  XXIII.  Treatment of Mania.......................   210
  XXIV.  Epilepsy, Masturbation and  Melancholia....   221
   XXV.  Heredity.................................   237
  XXVI.  Sympathetic Insanity......................   247
 XXVII.  The Borderland of Insanity................   254
XXVIII.  The Borderland of Insanity—(Continued).....265
  XXIX.  Aphasia...................................   285
   XXX.  Crime and Responsibility..................   291
  XXXI.  Legal Points  in  Relation to Insanity and
              Crime................................   309
 XXXII.   Medical  Witnesses  in the Courts............   315
Index..................                                •» x 
MENTAL  DISEASES.
CHAPTEK  I.
                   THE BRAIN.
It is not  my  intention  to  describe  in  detail the
anatomy of the brain.  You, no doubt, are well versed
in its structure, both gross and microsv&-pic, yet there
are many anomalies in the arrangement of its  blood
supply and cell clusterings, as  well as in the relation
of its nerve fibres, which are  of surpassing interest.
The organ of the mind is the capital of the body, and
all executive action of the whole organism, however
remote, is represented in it to a greater or less degree.
A few points in this relation are worthy of a passing
notice.  The first is in respect to the circulation. You
will  remember  the different provision  made on each
side of  the body for the outflow of arterial blood from
the aorta.  On  the right side,  and  near the outlet of
the heart, the arteria innominata is inserted into the
aorta.  About an inch and a half  from this point it
ends in  two arteries,  viz., the subclavian and the
common carotid.  This arrangement provides for only 
10
MENTAL DISEASES.
one aperture in the aorta for these two large  blood
vessels.   On the  left side  the two  corresponding
arteries spring independently from the aorta, and are
a considerable distance from the heart.   Why this
want of symmetry in both sides of the body ?  Nature
never does anything at haphazard, but always with a
purpose.    It has  no lumber-room  for useless fur-
nishings, neither has it changes,  but from design.  It
seems to me that only one outlet is made so near the
heart on the right  side for the two arteries, so as not
only to strengthen the aortic parietes at this  point,
but also not to diminish,  but  as little as possible,
lateral pressure  on the  blood flow by having  one
opening  instead of two  so  near the  outlet  of this
muscular pump.
  It is also worthy of remark, that while the arteria
innominata  springs at almost right angles from the
aorta, the left common carotid leaves it at an obtuse
angle, and to such an extent that the long axis of
both vessels is almost in a straight line, or with only
a slight  divergence.   This  statement is also true as
between the left  internal  carotid and the  middle
cerebral, so that  emboli floating in the  aorta more
readily find their way into  the  left hemisphere than
into the right.  The cuts in many books on anatomy
do not show this construction to the same extent as
is seen in the cadaver.
  The two internal  carotids  and the two vertebral
arteries on entering the skull make curvatures almost
like the letter S, which are possibly for the purpose 
THE  BRAIN.                  11
of breaking, to some extent, the force of the powerful
intermittent impulses of the heart upon the current
of blood sent into the delicate nerve structures of the
brain.   The goose-neck  flexures may possibly be also
to allow elongation of the arteries in the various and
extensive movements of the head. This arrangement
is also  seen  on the lower jaw,  in which is  much
movement, as exemplified in  the  facial artery and in
the internal maxillary and pterygoid portion of this
artery.
  The  next observable  arterial arrangement, as  our
search goes upwards, is the wonderful circle of Willis,
whose main object is to  enable the two vertebrals and
the two internal carotids to anastomose with  one
another.  This reservoir also  checks to some degree
the blood flow.  It  is a local supply  deposit which
may be necessary on a sudden  demand,  and as  the
carotids supply the  front part of  the encephalon and
the vertebrals through the basilar, the posterior part,
the communicating branches which compose the most
part of the circle are lines of supply  of  blood from
one part to another. This remarkable arrangement
is the  more  necessary,  seeing that in  the  further
progress of  the arteries to supply blood to the brain
proper,  they  seldom  intercommunicate   with  one
another.
  The next wonder upwards is the unusual distribu-
tion of blood on the surface of the brain, as from the
outside  the arteries  dip  into the  centre of the organ.
This is true of all the arterial blood in the  skull going 
12
MENTAL DISEASES.
to the brain, with  the  exception  of  a few nutrient
vessels which go into the  medullary substance from
the basal vessels.  We know this is not the arrange-
ment in the other  organs  of the  body, such  as  the
kidneys, the lungs and the  liver. In these, each large
artery seeks  the central portion and  from this point
sends out blood supply to the periphery.  In the con-
gestion  of  these organs  there is room to  expand  on
account of being surrounded by soft or yielding sub-
stances.  Not so with the brain, as it is enclosed in a
bony envelope which is unyielding, hence the least
hurtful  positions for the  blood  vessels  are  in  the
limited space between the brain and the skull, in the
openings between the hemispheres  and between them
and the cerebellum, as well as in the  ventricles, such
as we see in the  lateral  ventricles,  where a section of
the pia mater  is deposited  under the name  of  the
choroid plexus.   Did the comparatively large arteries
go into the centre of the brain and branch off" from
this  to  the cortical substance the result would  be
that in  active  or  passive congestions the  delicate
nerve substance  would  be  so impinged upon as  to
seriously, if not dangerous^, impair its function.
We  are to remember that so functionally active is
the brain that nearly one-fifth of  the whole blood of
the body is needed  to do its work.  When the blood
is largely sent along the various spaces in the skull
this untoward result is very much  minimized.   Room
is made in  dangerous   congestions   by driving  the
fluids of the brain for the time into and through  the 
THE  BRAIN.
13
hundreds  of  foramina in the skull  and in the spinal
column, and thus additional space is provided in such
emergencies.   In spite of this well-known fact, learned
treatises have been written  to  show  that brain con-
gestions is an impossibility  because of static impedi-
ments.
  The pia mater is the great arterial  reservoir of
blood from which the brain  is literally supplied.  It
is a close-fitting envelope on the surface of the brain,
dipping into  the sulci and  sending into the brain
substance vascular  loops of unequal  length.  These
anastomose very little with one another, nor  with the
central arteries, and each has its own returning vein
going into one of the sinuses.
  The  veins  which  go into the longitudinal sinus
have several  peculiarities.   In the first place they
run  from the arterioles away from the direction of
the  heart upwards, which is not the rule with the
other veins of the body. The second strange arrange-
ment is that the mouths of the veins enter the sinus
towards the  blood  current and not in its  direction.
It is possible  this construction  has  two objects in
vjew—the one being to prevent  the too rapid flow of
blood from the brain, and the other being to check the
current in the sinus, which might  otherwise  be too
impetuous, especially into that whirlpool of venous
blood, the torcular Herophili, where six large sinuses
converge  before taking the downward  direction to
the heart. A secondary  result of impetuosity would
be   to  draw too  rapidly  after the  venous  stream 
14
Mental diseases.
arterial blood before  it unloaded its vitalizing ele*
ments; not to speak of the venules not having time
to have their contents loaded with  the  dead matter
which is being constantly carried off in these ambu-
lances  of  nature  to  the  various excretories.   The
longitudinal sinus is connected with the outside parts
of the body in two  ways.   We know  congestive
headache is often relieved by epistaxis, because there
is a connection  between this sinus at its anterior part
and some  veins of the nostrils.   Then there is a con-
nection by means of many small veins  between  the
scalp, the diploe, the skull and  the sinus.   This is
why erysipelas in  the  scalp  is so dangerous, as it
often spreads inwards along  the veins and attacks
the meninges, and  even  the brain substance.   The
layers  of the grey  matter  are superimposed on  one
another like the coats of  an onion.  They are five in
number, although some German authors  say there are
seven.   With  these  your  anatomy has  made you
familiar,  although  the different laminse have  many
cells in common, yet each has  characteristic  cells,
largely distinguished by their shape.   The  round,
irregular,   ovoid,   pyramidal,   caudated,  fusiform,
spindled-shaped,  are names  which  indicate  their
form.  The  particular function of each class has so
far not been yet definitely determined.   Different
authors give the number  in  an average and fairly-
educated  brain  from  five  millions  up  to  sixty
millions.    There is no doubt the  number of  these
determine the  brain  capacity and not the size of 
THE  BRAIN.
15
brain nor the quantity of grey matter merely.  In
the child, the idiot and  the  savage they  are  com-
paratively few in comparison with the number found
in the active brain of a normal man.
  To reason from  analogy, it might  be suggested
that the layers of the surface, having comparatively
small cells,  may be  centres  of  sensation,  and the
deeper  layers,  in  which  are  giant cells, centres of
motion.
  In the spinal cord  there are  small cells in the
posterior cornua in which is  the seat of sensibility,
and the large cells in the anterior cornua, the seat of
impulses.   So it  is a fair inference to draw that the
cortical layer of the grey matter in the brain  is the
centre  of sensibility, and  the deeper layers, in  which
is the larger class of cells, the centre for energizing
and emitting motor stimuli.   The apices of the tri-
angular cells all point towards the  cortex as if they
were polarized.  There is no  doubt  each cell has an
autonomy, an individuality and an organic sensibility
of its own, and that clusters of them act in consensus
from  sympathetic  union  to  produce   combined
functional  results.  Such a community has a  head
centre  from which directions emanate to bring about
definite results, so we find in the order of complexity,
the neural  tissue made  up of nerves, ganglia and
centres.  Malpighi  discovered cells in A.D. 1687, and
described them, yet little notice  was  taken of this
important discovery for nearly 200 years afterwards.
   The brain is the larges mass of nerve substance 
16
MENTAL DISEASES.
contained in the body of any animal possessing a
brain.  The sum total  in  bulk of  all the other parts
of the nervous system cannot equal the brain.  In
its  absolute  weight  the  average human  brain  is
heavier than that of any other animal, except those
of the elephant and the whale, but these are of much
lower organization.  In relation to the weight of the
body  the brain exceeds that  of  all other animals.
The relative size of the brain is no criterion of intel-
ligence.  Man's brain  only averages  the  one-fiftieth
of the weight of  the  body.   A number of creatures
have  greater averages  than  this, and  with  little
mind power.
  The brain  is  very simple in its construction.  This
is necessary  when we  considered  its   many-sided
work.  Were it specialized as machines are  it  would
of necessity be limited in its  operations.  It is virtu-
ally a loose  structure  composed of cells, nerve fibres,
connective tissus and blood vessels, yet  it is the seat
of sensation, ideation,  volition, consciousness  and all
the phenomena which  are  seen in the  sensori-motor
and ideo-motor operations.    No  wonder  it  is the
centre of so much  speculation and investigation. 
 
Fig. 1.
Fig. 2. 
                              Fig. 3.
   1. Centre for motor aphasia (.Broca's region).
   2. Centre for sensory aphasia, speech images, auditory centre, word
deafness.
   3. Hypoglossal field.
   4. Facial field.
   5. Motor trigeminus field.
   6. Centre for agraphia.
   7. Centre for coarse arm movements.
   8. Centre for coarse leg movements.
   9. Centre for coarse arm and leg movements.
  10. Centre for complicated movements of hand, arm and legs.
  11. Supposed centre for levator palpebrae superiorie.
  12. Centre for disturbances in all sensory tracts.
  13. Centre for alexia.
  14. Visual centre.
  15. Doubtful centre for smell and taste.
Fig. 4 (after Ballet).
   (a) The region of print images.  (6) The region of language images.
(c) The region of speech images,  (d) The region of  writing  images.—
From Kirchhoff. 
 
MIND.
21
CHAPTEE II.
                      MIND.
Without going  into an unprofitable discussion as to
what  mind is, it may be  well  merely to epitomize
certain  general  statements as  to  its manifestations.
We are  not to forget, however, that  in  medical prac-
tice we  have to do with  a unity called  man.  This
integer  is composed of  two parts,  viz.:  Mind and
body, in mutual relations  and  inter-dependent  upon
one another.  When death severs these  the physician
and his  remedies cease to be of any avail.   Medical
men have to  do with life  and  not with death, hence
metaphysical subtleties are of  little practical benefit
to them in fighting  disease existing  in the human
organism.
   Suffice it to  say that  the definitions of mind are
usually classified as follows :—
   1. The metaphysical,  (a) The  mind as a distinct
entity from matter ; (6) As proof of this, an appeal is
made to  the evidence of  consciousness.   Descartes'
presumed axiom is accepted: " I think, therefore, I
am "  (Cogito ergo sum).   He assumed the existence
of the Ego as a self-evident fact based upon conscious-
ness.  An  inference is also  drawn  from the  varied
manifestations observed in all  mental phenomena, as 
22
MENTAL DISEASES;
known in ourselves and seen in others  by conduct.
These  proofs  are two-fold, subjective and  objective.
I study my own mind in its varied moods, and I ob-
serve what is being done by others of my race under
like conditions of existence.
  2. The  study  of neurology  presents additional
proof.  The study of our bodies and of all animated
nature in relation  to mental tone and scope through
nerve  instrumentality  is  doing much  to enlighten
us about this  mysterious  union of the Ego and the
Non-ego.  Embryology, physiology, in short, biologyr
in all  its  wide  domain,  and  pathology are doing
wonders  in  this  direction.   The  close study  of  the
growth of nerve substance and  the corresponding ex-
pansive of  the powers of  the mind in juxtaposition
and correlation to it, promise much in the future to
solve the mysterious union.
  Metaphysical writers hold that  consciousness is the
fundamental condition of all intelligence, and consists
of Feeling, Volition and Thought.   On the other hand,
many physiologists of to-day do not thus circumscribe
mind activity.   They hold that mental powers do not
solely reside in the brain.   Mind  means nerve action
of all kinds, whether in the  brain, the spinal cor'd, or
the sympathetic system.  It will  be remembered the
ancient Greeks and Romans held that soul (psuche)
resided in  every living tiling, vegetable as well as
animal.  The trend of opinion to-day is in that direc-
tion.  This is,  however, a matter of definition.
  We do not know what mind is.  We only know it 
MIND.
23
by  its  manifestations.   Its  essence is an  unknown
quantity.   This is true  of everything created.  We
are in the dark in respect to the atoms and molecules,
and their  groupings in chemical elements.  We know
nothing of the working of the ultimate elements  of
plant life  in their selective power.  Our bodies are in
every different structure, various work-shops, which
never make mistakes in building up cells, each accord-
ing to  its kind.   Yet there is  a world of atoms  of
which they are composed beyond our  ken.  Here our
explorations end,  even  in the primordial and simple
protoplasm.   It  is  not to be  wondered, then,  that
mind, in  essence, has eluded  our most  searching ex-
plorations.   As a mental  exercise it is  interesting to
study the  history  of  mental  philosophy  from  the
early ages downwards to the  present  day.  Going no
further back than Lucretius, in his wonderful book
De Rerum Natural, which contains the well-known
statement that "matter  has  in it the promise and
potency of life," we find a materialism, or rather pan-
theism, which crops up in Shelley's Queen Mab :—
        '' Infinity within, infinity without,
                 Belie creation :
          The inexterminable it contains,
                 Is nature's only God."
   So intimately related are mind  and body  that in
 medicine they are treated La a unity.   The one affects
 the other so sympathetically that they seem, in fact, as
 one organism.  Sleep is physically demanded because
 of exhaustion ;  yet it  means  total  unconsciousness. 
24
MENTAL DISEASES.
The strongest will cannot resist the soporific effect
of a dose of opium, and the wisest  philosopher will
act  silly from  the  effect  of  a stimulant such  as
alcohol.  The poison  of a fever will cause delirium,
and  a blow on the head may  produce nonsensical
utterances, a felon on the finger or  a  toothache affects
concentration of thought, and would handicap a stu-
dent passing his examination or  a clergyman writing
a sermon.   On the other hand, a profound emotion
may, and often does, produce insanity, and even death.
The best appetite is immediately spoiled on  the recep-
tion of bad news, and good tidings act as a powerful
tonic on our bodies.  It is evident to every physician
that, in treating man, he does so as  an  individual.
Metaphysical subtleties as to our being dual or tripar-
tite do not enter into his practice.   There has been a
sort of development of opinion in respect to mind
throughout the centuries.  The trend has been evolu-
tionary, yet every now and then a reaction would take
place, because of the powerful writings of  some able
metaphysician, whose reasonings would hold sway for
many years  among the learned of a country.
  As Bain succinctly puts it in " Body and  Mind."
  I. Mind  is  two substances.   1st. Both  material ;
(a) The prevailing conception among the lower races 5
(6) The opinion of most of the ancient  philosophers '
(c) Held  by the early Christian Fathers.
  2nd. One  immaterial and one material ;  (a)  Com-
mencing with Plato and with Aristotle ; (6) The later
Fathers from the age of  Augustine ; (c) The School-
man ;  (d)  Descartes ; (e)  The prevalent opinion. 
MIND.
25
  II.  1st. Mind and matter the  same; that is, identi-
cal ; (a)  The cruder forms  and expressions of materi-
alism  ; (b) The pantheistic idealism of Fichte.
  2nd. Contrasts  of  mind and  matter as  effect and
cause. A guarded or qualified  materialism  held by
many physiologists and metaphysicians of  to-day.
  In  addition  to  these views we have those of the
theologians  who hold that man is a  tripartite being
composed of body,  soul  and spirit.    One  of  these
psychic  entities is held by such to  mean a higher
power and  non-corporeal  substance,  having  capacity
to formulate abstract ideas, to grasp to some degree
the conceptions of  time and space, and in the ethical
world, to reach beyond the brute creation, in forming
and   estimating  moral  judgments.   Many of  our
ablest biologists  hold that  the minds of man and
animals  are similar in essence, but  that of man by
evolutional  growth has much greater capacity, which
is crowned  by  that faculty of man through which he
can   create  moral judgments  and  appreciate  their
value in his daily conduct or in that  of others.
   Such  modern thinkers as Lotze are believers in the
existence of a soul-entity, and not a mere nerve secre-
tion.   They hold that no discoveries in mechanical and
biological exploration can annihilate  that entity in
which is spiritual force, but which is a substance and
not   gross  matter.   He  bases his  opinions on the
unity of self-consciousness.   We  cannot predicate of
 this  Ego any  quality or property which is indispen-
 sible to  the existence of matter. 
26               MENTAL DISEASES.
  Wundt, on  the other hand, scouts the argument
based on conscious states, and holds the mind to be
complex, and that consciousness is only an act of con-
centrated attention ; that it is meaningless to speak of
a spiritual substratum, that it is only material pheno-
mena, or attributes inherent in matter.   When great
minds thus differ we  can patiently  wait for  further
developments.
  Psycho-physics are at present  commanding a good
deal of attention, especially  in  child-growth.   The
gradual * development  of  body  and mind, and the
order of  sequence in ideation in  the young, from the
simple to the complex and  from the concrete to the
abstract, is an inviting field for research.
  The  dawn of  the intellectual life  and the  gradual
growth  of the aesthetic and ethical elements in the
juvenile  mind under normal conditions  must be sub-
jects of  surpassing interest, not  only to the philoso-
pher, but also to the alienist.
  The literature of the day shows that many  able
minds  are being directed to the study of the evolu-
tion of mind along these lines, with great promise of
fruitage. 
BR A IN PATHOLOGY.              27
CHAPTEK  III
             BRAIN  PATHOLOGY.
Much cannot be said here upon that extensive subject,
Brain Pathology.  A few pointers are all which can
be recorded.
  As a rule, the size of the head of the insane is below
that of the sane.  This is not always the case.  There
is in the majority of  the insane a want of symmetry
in the skull; the one side being flatter or smaller than
the other.   Sometimes  the  skull  is high and dome-
like ; sometimes compressed laterally, and  in others
keel-shaped.  These  abnormalities are seen among
the chronics, as it needs time to produce them.
  The  most common changes  in the  membranes are
those  of thickening  and opacity.  In  the pia mater
is  found,  in addition,  condensation and a varicose
condition of the vessels.  In insanity, the exudations
of the  pia mater are not organizable.  When adhe-
sions are found between the pia mater and the grey
matter, as seen in paresis, the connections are probable;
through the connective tissue  of the grey matter.
Congestion of the pia mater and serous effusion into
its meshes are always found in atrophy of  the brain.
The vacancy made because of the shrinkage, is filled in
this way.  In vigor and health the apices of the convo- 
28              MENTAL DISEASES.
lutions are on a plain.  In old age there is an uneven
atrophy apparent.  This progressive shrinkage is also
seen in premature dotage, especially if brought about
by alcoholism.  An uneven atrophy is always seen in
cases of paralytic dementia, and  in  chronic dementia
and melancholia.
  When such a degenerative  condition  is found, the
colour  changes from a normal grey to  a  yellowish
white, doubtless, because of the nerve cells decaying
into a granulo-fatty substance.
  Out of sixty-three brains examined by Tucke, there
was  an average atrophy of o\  oz.  per brain among the
chronic insane.  In thirteen  of  these  patients,  who
were over sixty-five years of age, the average amount
of lost substance was 8| oz.   A few were atrophied
as  much  as  14  oz.  Normal  atrophy commences
between fifty and fifty-five years of age, and in some
at forty-five years of age.  In such, shrinkage is not
condensation and increase of specific gravity, but a
loss of  material.  There are many exceptions to this
rule.  A very little added to  or  taken from  the sur-
face of a round or ovoid body, means a great deal in
the sum total, as our  knowledge of the measurements
of such shaped solids indicates.  It is a matter of cubic
calculation, and not of a mere superficial area.
  When measuring the cavity of the skull, about 15
per cent, is deducted for  space  not occupied by the
brain.   The average specific gravity in health is 1,04-0,
ranging from 1,026 to 1,046 and  upwards.
  The  specific  gravity may diminish  by effusion of 
BRAIN PATHOLOGY.
29
serum, or by  the  accumulation of fat  globules.   In
softening, fatty matter predominates.  In degenera-
tion the organic elements  are apt  to change  into the
form of the hydro-carbonates.
  Inflammation is seldom a primary cause of insanity.
It may be in a secondary way.   The organizable pro-
ducts in inflammation  may, after it  subsides, remain,
and by contraction  affect  and partially impede blood
flow in  the  meninges,  and in cerebritis produce, as a
result, atrophy of the brain tissues.  We see this con-
dition in atrophy of the  liver, from inflammation of
Glisson's capsule.
  Because of  any such impediments to vital action,
stasis may  take place by  adherence of blood cor-
puscles  to  the  arterial walls  and  thereby  prevent
plasmic exudation,  or  excessive nutritive exudation
may cause hypertrophy, and thus impede functional
action by pressure.
  We have also hypertrophy largely  made up  of
adventitious  tissue, amyloid  corpuscles,  calcareous
and fatty granules.  All  are evidences  of retrograde
metamorphosis.  Connective tissue may take the place
of nerve substance,  or it may be an  increase  of other
depreciated elements of a low order.
  We may have substances  formed in a normal way,
but after being built up they deteriorate in structure,
vitality and tone.
  We may  have in brain disease then as causes of
insanity:                                          ,
  1st. Subacute inflammatory degeneration.  In this 
30
MENTAL DISEASES.
congested condition there are no fibrin exudates and
no pus cells, as seen in cerebritis.
  2nd". Chronic hyperemia.
  3rd. Fatty degeneration (a) as found in small blood
vessels;  (b)  in nerve elements; (c)  in  new morbid
products; (d) in retrograde changes of hypertrophied
connective tissue.
  4th. Amyloid degeneration, as seen in  little starch-
like bodies which give starch reaction.
  5th. Pigmentary degeneration, which is mostly met
with in the ganglionic centres.
  6th. There is  derangement of the connection be-
tween the nervous  and  vascular  systems,  causing
disease of the minute cerebral vessels, in  the form of
fatty  or calcareous decay in the coats.
  7th. Albuminous matter may exist or serous fluid
may be effused into the structure  of the brain, and
thereby separate vessels, tubules, fibres and cells.
  8th. Molecular changes take place in same way by
the means of  blows, violent concussions, vitiated blood,
emotional storms and such like.  These changes may
be very serious, yet beyond the search of the scalpel,
the microscope and micro-photography.
  9th. The blood  supply is  an important factor in
insanity.  Deficient  quantity and quality act  upon
the nerve centres  and these  react  upon  the vessels,
thus brain structure and function are affected. Heart
troubles are very common among the insane, and the
blood circulation is affected thereby.  Fatty degenera-
tion of the heart means loss of muscular tone, con- 
BRAIN  PATHOLOGY.
31
sequently feeble contraction and  blood  flow,  hence
low brain vitality.   Imperfection in the aortic valves
means regurgitation and  clot formation, and embolic
results.  Aortic aneurism is followed by a slow blood
flow from the heart, feeble impulse and the existence
of clot, hence embolism. In addition to these untoward
conditions we  often  find  hypertrophy  of the left
ventricle, which of  necessity hinders systolic action.
   10th. Many of the cells seen in senile atrophy look
in the microscope like little blackish-brown spots, and
mi^ht easily be  mistaken for blood clots.  The opthal-
miscope often shows this  condition in the retina.
   11th. Calcification takes place in the cells as well as
in the coats of the arteries.   It is a return of a living
cell  to the primitive  form  of  dead  matter.   The
retrograde  step to  disintegration  is " to the  earth,
earthy."
   12th. Maudsley, in his " Pathology of  Insanity,"
well  describes  the  unknowable  pathological  con-
ditions :  " There are numerous facts available to prove
that  the  serious modifications in the constitution of
nerve element  many take place without any know-
ledge  of them  otherwise than by  the correlation of
energy.   After  great and prolonged  mental exertion,
there  inevitably comes exhaustion, which may be so
great  that  the brain is  utterly incapacitated for
further function.   A greater increase  of phosphates
in the urine  testifies  to  the  disintegration  of  nerve,
yet neither  microscopist nor morbid anatomist would
succeed in discovering any  difference between the 
32              MENTAL DISEASES.
nerve substance of the brain of one  who, after due
rest and nutrition, was prepared for a day of vigorous
activity."
  The sudden shock of a powerful emotion may pro-
duce instantaneous death, just as a stroke of lightning
may end life perhaps in the same way, but neither in
the one case nor in the other may there be any detect-
able  change.  Electric fish are exhausted by constant
irritation,  but there  is  no  apparent nerve change.
Carbonic acid kills.  So do such poisons as strychnine,
aconite  and such like, but beyond  temporary blood
congestion  they leave no  sign.  Mechanical, chemical
and  life changes doubtless do take place, but there
may be  no physical evidence of them.  The  change
is  molecular  and  beyond human  ken,  just as is
seen  by  the blow of a hammer on a magnet lying on
an anvil when it is  demagnetized  at once, but  no
microscope nor  chemical  analysis  can detect the
atomic change.  A colourless chemical solution of salts,
which will change their affinities when brought in con-
tact, do  so in  the common fluid without possibility of
detection by  eyesight, yet when evaporation  takes
place and chrystals are formed it is found that new com-
pounds with new forms and new properties have been
generated when the  molecules were beyond  human
observation.  It is not to be wondered  then that great
changes may take place in the  ultimate  elements of
the brain   producing  mental  dethronement and not
discernible by our inspection.
  We are not to forget what pathology has taught us 
BRAIN  PATHOLOGY.               33
as existing in all diseased conditions of the physical
system, and which has divided such into two classes.
   1st.  Infiltration.  This is  a passive process and
means excessive normal deposit out of  place.
   The fatty, calcareous, the amyloid and pigmentary
degenerations are in the  nature  of chemical rather
than vital processes, and are often  found in old age.
The phosphates and carbonates of lime are normal
constituents of the  nutritive fluid, as well as are the
albuminates.  The former are chiefly found  in the
coats of arteries just  as fats are found in liver  cells,
muscles and nerve substances to excess.
   2nd. Involution.—This is a physiological  process.
The type of a structure  is changed from its normal
condition.   It is a metamorphosis of tissue and not a
deposit.   It  commences  in  a cell, and  changes  its
nature.  It is a living formation, and  not merely an
inert deposition.   It can reproduce  itself as a normal
growth does, but mere deposits can do so only  by
infiltration.
   There are four recognized forms  of involution:  (ai
Fatty metamorphosis ; (6) cloudy swelling; (c) mucoid
softening ;  (d) colloid degeneration.
   What has been at first abnormal may continue in
this state, and after a  time will put on  a physiological
habit.   We see  this  law of  repair as  a legacy in
zymotic diseases, and an irregular habit of functional
activity may be seen  in  special organs, such as the
stomach, the kidneys  and the uterus.   In all such it
is in fact perverted  nutrition assuming a normal law.
a 
34
MENTAL DISEASES.
A scar reproduces a scar.  A callous, where a fracture
of bone existed, remains as such throughout a long
life.  The adhesions of pleurisy or peritonitis organize
and reproduce themselves as readily as normal struc-
ture.   Adventitious tissue  reproduces itself  in  all
parts of the body when it assumes a permanent form.
so when insanity takes  place,  at first it produces
pathological changes of a pronounced kind.   Mental
abnormality arises  therefrom, when recovery takes
place and the  mind seems to  assume its normal con-
dition  an  abnormal habit has  been formed  which
leaves  in a  comparatively healthy state  mental ab-
normalities.   Patients, of whose  recovery we have no
doubt,  state  candidly that they  have not the mental
robustness they formerly had,  although to an outside
observer no  weakness in mental  capacity is observed.
It is possible that disease which  attacks tissues never
has all its  foot-prints  eradicated,  but always  leaves
traces of its visit behind after its invasion has  ceased
to be aggressive.
  In all forms of insanity there  are two classes of
lesions, as some one has well stated, viz.:
  1st.  The  constructive.  These  include disorders of
function and  structure,  such  as  are involved in
inanition,  indigestion,  malnutrition,  malassimilation
and toxic effects.
  To counterbalance these disturbing  elements  and
agency, we need two classes of  remedies: (a) The class
which  gives nutrition;  (b) the depurating class.  The 
BRAIN PATHOLOGY.
35
former furnishes  building-up  material, and the latter
rids the system of effete and toxic accumulations.
  2nd. The second-class  of  diseases  may be called
the destructive.  They embrace the various cachexias,
such as cancerous, syphilitic, tuberculous, the athero-
matous and other forms of degeneration.
  The treatment  in this class  must be tonic, stimulant
or alterative.  In  the former class, nature is hampered
for  want  of  material.   In  the latter  class, gross
pathological changes have taken place.   In treating
insanity these facts require to be noted.

               Clinical Conditions.
  Insanity may develop because  of clinical conditions,
such  as we find in :
  1st. Anaemic insanity, which  may be  from malas-
similation and consequent brain starvation, or chlor-
osis, or indigestion, with consequent blood impoverish-
ment.
  2nd. Diabetic insanity from blood poisoning.—
Post-mortems  show  want of brain  nutrition, conse-
quently atrophy of the cortical substance.   These two
classes of patients are usually  afflicted  with melan-
choly.
   3rd. Insanity of  Bright's disease.—In this  also
there is blood contamination, weak  heart action, and
as a resultant of these two conditions we have dr.opsy.
 Such cases are mostly maniacal, because of the toxic
 agents affecting  the great nerve centre, and which
 have not been eliminated. 
36
MENTAL DISEASES.
   4th.  The metastatic insanity is far  from being
seldom seen.  The nerve centres are often attacked
because of rheumatic  conditions.   When  syphilitic
psoriasis disappears, or old ulcers heal up, or erysipelas
suddenly departs,  or  asthma  is  relieved, then in a
substitutionary way some form of insanity supervenes.
   In addition to  these  metastatic changes  we  see
insanity  occur  in  the  inanition  succeeding acute
febrile diseases, such as typhoid,  in puerperal  condi-
tions, in  peritonitis, in persistent  malarious fevers,
after the exhaustion of surgical operations,  and after
an attack of la grippe, whether this is thoracic, abdom-
inal  or affecting the nerve centres alone.
  These,  and such  diseases,  may not be' causes of
insanity, but having established bodily weakness, the
mental enfeeblement, heretofore latent, becomes mani-
fest,  and takes active  possession  of the brain to  its
hurt. 
INSANITY—WHAT IT  IS NOT.
37
                CHAPTER IV.


          INSANITY—WHAT IT IS NOT.
It is not mere eccentricity.  That is congenital.  The
oddity is natural to the individual, hence this warp is
not a diseased condition.
  It is not crankism.  That means the turning of the
crank of one  idea  to the partial  exclusion of other
modes of thought.  This is seen in every  genius, who
has made his life-work turn in one direction, and who
is usually good for  little  in every  other  mode  of
thought.  The crank may be  useful or useless, harm-
less or vicious, silly or scholastic,  according to his bent
of mind.  He  may be naturally  a man controlled by
a dominant idea, or  this one-sidedness may be inten-
sified by education or environment.  He  is, however,
not insane.
   The  delirium or  mania induced  by  fever,  toxic
agents, such as alcohol, opium and its salts, cocaine,
hydrate chloral and  such like, are not insane condi-
tions.   They are fugitive in cause  and sequence.
   The natural decay of old age, with its loss of mem-
ory,  its childishness, and  even its  delusions,  is  a
senility progressing along natural lines of decadence.
Unmistakable insane conditions must exist,superadded
to senile failure, in order to constitute mental disease. 
38               MENTAL DISEASES.
   Idiocy  or imbecility  are  simply  arrested  brain
development from  nutritive or trophic defect,  with
the consequent mental limitation.  This stunted con-
dition is  brought  about  along  physiological,  not
pathological, lines, therefore is not insanity.
   The delirium which precedes death,  hysteria  and
simple hypochondriasis are  too temporary, evanescent
or intermittent to constitute psychic disease.
   A number of these conditions are  classed by some
authors as insanities under the head of " Toxic Insani-
ties," and are classified as saturnine insanity, alcoholic
insanity, morphinic insanity, haschish insanity, etheric
insanity,  chloralic  insanity,  cocainic  insanity,  and
<oxy-carbonic insanity.
   On a pathological basis these distinctions are fanci-
ful arid  finical, unless a permanent  mental disease
follows the use of and abstinence  from these drugs.
Even then the  toxic influence may not be the cause
but only the occasion of insane manifestations.   Un-
less we adhere  to morbid conditions as a basis of our
definition of insanity, then no definite formula can be
given.  Mere ephemeral states cannot be classified.

                     Insanity.
   Insanity is a fixed physical disease, which affects
and controls abnormally the language, conduct  and
natural characteristics of the individual.
   Any definition of insanity must,  of  necessity, be of
a general character, as the signs and symptoms vary
as does  each individual  from  any other  person in 
            INSANITY—WHAT IT IS  NOT.          39

physical and  in mental elements.    The  definition
given might be analyzed as  follows:—
  1st.  Fixed, to distinguish it from the fugitive effects
of toxic agents, from the deliriums of fever, and such
like temporary mental unbalance.
  2nd. It is always a physical  disease.   There is no
reason to  believe that the entity called mind is ever
diseased.  If the organ  through which it  makes itself
manifest is in tune, then will the operator  be able to
healthily  make known its  normal  condition.  The
medium is at fault, and not the  agent.
  The term physical is  used instead of simply brain
disease, because in a large  class of  insane the causes
primarily are  found in  parts of the body outside the
skull.
  We  observe  this in  puerperal  insanity, insanity
from heart disease, insanity  from dyspepsia,  or from
kidney troubles.   It is true, these disturbing centres
may only be the occasion  rather than  the cause if
hereditary conditions  exist.  Yet, the initiatory im-
pulse is given fro"m without.
  The reflexes and their potency in disease are being
better understood now-a-days,  and  in no realm  of
medicine is a knowledge of them of more importance
than in nervous and mental  abnormalities.
  Until a comparatively recent period the  locality of
a disease, when discovered,  was thought  sufficient for
our diagnosis ; but now we  find it  necessary to take
into consideration the trophic centres and the sympa-
thetic relations of the parts affected. 
40
MENTAL DISEASES.
  3rd.  The disease  is abnormal to each individual.
The  natural  traits  and idiosyncrasies are changed,
so we have in common use the phrase:  "He  is not
himself."  In studying an insane individual we must
measure his present conditions by the healthy standard
of himself.  We have  no common measurement  of
mankind as we  have in cubic and lineal dimensions
in the British Museum.  As there are  no  two persons
alike, except in a very general way, so no true estimate
can be made  of  any man's mental  condition by com-
paring him with anyone else.
  4th.  It will not do to judge by language alone, nor
even by conduct alone.   We  must form an opinion
based upon all the  elements which are characteristic
of the  new  departure  from  the life  history  of the
individual placed in juxtaposition with previous habits,
traits and experiences.  On the one  hand, we have
natural, mental equilibrium;  and, on the  other, men-
tal inco-ordination.

                 Classification.

  To enumerate the classifications of authors would
alone fill a good-sized volume.  Each  writer launches
into emendations on the groupings of his  cotempor-
aries or predecessors as he supposes his own produc-
tions to excel.
  Associations  have taken up  the task,  but with
indifferent success.   This is to be expected in attempt-
ing to classify phenomena which  change  in  details
almost as much as  one person  differs from another. 
            INSANITY—WHAT  IT IS NOT.          41

Any attempt  in  that direction must  be  of a  very
general nature.   We  see  mania  exhibited in  mild
forms of dementia, melancholia and excitement coin-
habit in the same patient at the same time.   The
same is true of melancholia and semi-dementia.  We
have in progressive paresis, during its different stages,
almost all external  forms of mental abnormality.
  At the same time,  it is important to have  some
knowledge  of the best known groupings.   Skae's
classification is held by many alienists to be the best.
He  follows the plan of Morel and Kolk, and  looks
upon mental  disease  from a  clinical standpoint.  In
other words, he attempts to put in groups the pheno-
mena of mind disease, and thus, as it were, give  a
natural history of it.   It is too  complicated  to be
practical in the study of the various kinds of insanity.
It will be seen, however, it is  not  entirely serological,
but is an attempt iu that direction.  It is as follows :
   (1)  General  paralysis;  (2)  Paralytic  insanity
(organic dementia); (3) Traumatic insanity ;  (4) Epil-
eptic insanity; (5) Syphilitic .insanity ; (6) Alcoholic
and toxic  insanity;  (7) Rheumatic and Choreic in-
sanity ;  (8) Gouty (Podagrous) insanity ; (9) Phthis-
ical insanity; (10) Uterine  insanity;   (11) Ovarian
insanity; (12) Hysterical  insanity : (13) Masturbatic
insanity;  (14) Puerperal  insanity;  (15) Lactational
insanity; (16) Insanity of pregnancy;  (17;  Insanity
of  puberty ;  (18)  Climacteric  insanity ;  (19) Senile
insanity ; (20) Anaemic insanity  ; (21) Diabetic in-
 sanity ; (22) Insanity from Bright's Disease ;  (23) The 
42               MENTAL DISEASES.
insanity of oxaluria and phosphaturia;  (24) Insanity
of  cyanosis  from  bronchitis,  cardiac   disease  and
asthma;  (25) Metastatic; (26)  Post-febrile insanity;
(27) Insanity from  deprivation  of the  senses;  (28)
The insanity  of Myxoedema;  (29)  The insanity of
Exophthalmic goitre ;   (30)  The  delirium of  young
children;  (31) The insanity  of lead  poisoning ;  (32)
Post-connubial insanity ; (33) The pseudo-insanity of
somnambulism.
  It need scarcely be stated  that these  divisions are
arbitrary, too minute, and put into prominence minor
symptoms  which are not causes  nor occasions of in-
sanity, but  are  only  concomitants of  deep-seated
diseased  conditions, whose  latency  has been made
manifest  by favourable conditions  being produced.
No man could go into any asylum and group patients
into the infinitesimal assortment  of Skae's classifica-
tion.
  There is a great deal of force in what Dr. Pritchard
wrote, over seventy years ago, on this matter, viz.:
  " I cannot conceive  anything more preposterously
absurd than  to attempt to classify diseases  with all
the divisions1 and technology  of a botanical or zoolog-
ical system, and to  force what  is  essentially disorder
and confusion to assume the  appearance  of that order
and symmetry which nature displays in the arrange-
ment of the organized  world."
  Clouston endeavours to classify according to symp-
toms, and because of this method it is more practical, 
            INSANITY—WHAT IT IS NOT.          43

although  somewhat pedantic.  The  grouping  is as
follows :
  Melancholia  (Psychalgia),  mania  (psychlampsia),
circular insanity (psychorhythm), dementia (psycho-
paresis), mental stupor (psychocoma), defective inhibi-
tion (psychokinesia), insane diathesis (psychoneurosis),
fixed and  limited delusions (monopsychosis).
  The  Medico-Pyschological  Association  of  Great
Britain has adopted the following classification  :
  1st, Congenital or infantile mental deficiency ; 2nd,"
epilepsy with insanity ; 3rd, general paralysis of the
insane ; 4th, mania ; 5th, melancholia ;  6th, dementia ;
7th~ delusional insanity ; 8th, moral insanity.
   This classification has  been virtually accepted by
the American  Medico-Psychological Association, with
 the exception of the division under the heading of
 " Moral Insanity," which unjustly seems to have fallen
 into disrepute,  simply because of a lax  definition
 having been applied to it in some of the courts of the
 United States, and thereby criminals escaped unwhipt
 of  justice.
    German alienists  are divided on this subject, the
 one class adopting tables  based on mental manifesta-
 tions  solely, and the other on  bodily conditions.
    Bucknill, in his Psychological Medicine  makes an
 attempt  to  combine both the somatic  and psychical
 symptoms in a study  of  the different  forms  of
 insanity.
    As a historic  fact, it is worthy of note that a com-
 mission appointed at a congress held  in Antwerp  in 
44               MENTAL DISEASES.
1885, brought in a plan, and presented it to the Con-      )
gress held  at Paris in  1889.  It was  adopted, and is
as follows :
  (1) Mania, (2)  melancholia, (3) periodical insanity,
(4) progressive systematical insanity, (5) dementia (6)
organic and senile dementia, (7)  general  paralysis, (8)
insane  neurosis,  (9) toxic insanity, (10)  moral and
impulsive insanity, (11) idiocy.
  Professor Krafft-Ebing,  a  distinguished  German
alienist, has a classification with seventeen divisions
and forty-one sub-divisions.
  These varied classes, arranged by different authors,
show how difficult it is  to go beyond general features
in the groupings.
  Hippocrates and Celsus recognized only three states
of insanity, viz.: Mania,  melancholia  and dementia.
Ancient  Roman  jurisprudence  accepted  only  two
classes ; that is, mania (furiosi) and dementia (mente
capti.)
  The  metaphysical  divisions  are:   1st,  Insanity
affecting the  intellect;  2nd, the feelings and moral
sentiments ; 3rd, the propensities or instincts.
   The  forms of insanity usually adopted by us in this
country, and incorporated in our jurisprudence, are:
(1) Mania (acute, chronic  or recurrent), (2)  melan-
cholia  (acute  or  chronic), (3) dementia (primary  or
secondary), (4)  amentia  (idiocy or  imbecility),  (5)
general paralysis of the insane.
   Insanity can be studied from three  distinct stand-
points : 
            INSANITY—WHAT  IT  IS NOT.          45

  1st. An insane patient is diseased and needs medi-
cal  treatment.  He is the object of  a  physician's
care.
  2nd. He is irresponsible, hence not amenable  to
law  and its punishment when violated.  He  can  be
deprived  of  his liberty  without  perpetrating  any
crime  because  of  his helplessness,  or  because  of
danger  to himself  or  others.  He is the object  of
medico-legal  enactment  as children  or idiots are  of
necessity, because of defective or undeveloped intel-
lects.
  3rd. There is a sum total view of insane conditions
in which  all the  mental problems  are considered.
This  may be called the medico-psychological aspect
of such cases.
                    Memoranda.

  It  is well  to  put in a systematic way the notes
which should be taken at every examination of a luna-
tic  or a  supposed lunatic.   A case  book should  be
kept for this purpose as it is often necessary  to refer
to these, long after the enquiry has been made.   This
caution is especially  needed  should litigation arise
based on  the insanity of such a  patient.   Memory is
treacherous,  but a  record is  not  apt to be.  It might
be put in some such form as  the following:
                   LIFE  HISTORY.

   Previous attacks, if any; number  and character of
 each. 
46               MENTAL DISEASES.
               HEREDITARY HISTORY.
  Age of parents; relationship of parents  or grand-
parents ; health  of  the same;  family diseases and
kind;  peculiarities of  character ; consumption, hys-
teria, epilepsy, narcomania, or any  of  the numerous
nervous disorders.
               PREDISPOSING CAUSES.
  Worry,  over-work,  dipsomania, habits,   calling,
infantile  diseases,  child-bearing,   fever,  traumatic
injuries.
                 EXCITING CAUSES.
  1st.  The moral causes, such as those of the emotions,
the passions and  inordinate desires.
  2nd. Physical causes, such  as those acting directly
on the brain, or sympathetically;  anaemia, cachexia,
or any diathesis.   The two classes of necessity over-
lap, so they might be  grouped into (a) local causes,
(b) general causes, (c) physiological causes, (d) specific
causes. 
A DELUSION.
47
                CHAPTER V.


                  A  DELUSION.
  A delusion is a  false concept.  It  is an idea
generated in the  mind and  not  immediately sug-
gested by the organs of perception.
  If an insane man believes himself to be a monarch,
or a demon, or a diety, or being composed of glass, or
being any other absurd  or impossible thing, he is the
victim of any  insane  delusion.  Strictly speaking,
illusions and hallucinations are delusions as they also
are false ideas  in respect  to the objective  world.
These definitions  overlap each other, but all mean in
the end false conceptions.  A mere  delusion is not in
itself any evidence of mental  dethronement.  It is a
common mistake  to think  that the false beliefs of
the insane must of necessity differ from the delusions
of the sane.  The impression  is that those  of the
former are controlling influences in conduct, are fixed
and cannot be reasoned away,  which is held not to be
the case with the  sane.  This view is an error and
against  human  experience.   The  delusions  of the
insane are often  evanescent, have  little  or no  effect
on  daily life and, if  feeble, may be reasoned away.
On the  other  hand,  the sane  may  have  false,  fixed
beliefs, to which they may cling with stubborn  tena- 
48
MENTAL DISEASES.
city.  The superstitions of the hundreds  of  millions
of heathendom, the mythologic delusions of classic
and  educated Greece and  Rome, the  absurd beliefs
of many religions, from fetechism to the more subtle
aspects  of many creeds  and dogmas, the accepted
quackeries by even the educated, the incredible fads,
more extravagant than any insane mind would accept
as real beliefs, and the quasi-science and varied fana-
ticisms existing up  to this hour, show that delusions
are legion among the sane ; and, stranger  than all, in
which  they have implicit faith, even to the death of
martyrdom.
  The- mere existence of a delusion  is  not  per se  an
evidence of mental disease.   Race, religion, educa-
tion and  environment must be taken  into considera-
tion, as  well  as mental calibre.  All  these must  be
considered,  and  from  the stand-point of  a  person
handicapped along  such  lines a delusion must  be
judged.   Cetewayo, the Zulu king, was full of delu-
sions, as  were also his followers, but if even  he had
declared  that he was  a  walking assegais, with head
and  feet attached,  the most ignorant of his tribe
would say he had lost his  head.
  Demosthenes would  have been declared insane  by
the Greeks if, in his Phillipics against the Macedonian
king, he had declared that he had fought  at Thermo-
polae, had led the Greeks at Marathon and  Platcea,
and had  commanded at the naval battle of Salamis.
At the same time, he and  his countrymen believed in
many gods, omens without number, and saw in every 
A DELUSION.                  49
convulsion of nature the mysterious working of some
malign  diety.   Credulous as we  are  in many other
directions, we know that  all such were the delusions
of brainy and intelligent  men.  Analogous examples
might be produced from the history of Judaea,  Egypt,
or Rome, or from any of the great nations of ancient
or modern times, not to speak of the ghosts, fairies and
hobgoblins of  our fathers.  Enough has been  said to
show that insanity is  a question of diagnosis which
unreasonable delusions may and often do corroberate,
but having due regard to all the factors specified in
our estimate of mental obliquity or health.
   There are many forms of insanity without delusions;
and, on the other hand, the delusive  idea in itself is
not  alone  diagnostic  of  insanity, unless it has the
element of impossibility in it under the circumstances.
   Delusions are as various  as are the manifestations
of human thought.  They have been  classified  by
Ball  and  Ritti as follows,  viz.:  (1) Delusions  of
satisfactions, of grandeur, of  riches; (2) delusions  of
humility, despair,  ruin, culpability; (3) delusions  of
persecution; (4) hypochondriacal delusions; (5) reli-
gious delusions ; (6) erotic delusions ;  (7) delusions of
bodily transformation.

                  Hallucinations.
   A  hallucination is  a  false  perception, as  is  an
illusion, but it differs from  it in being false in  its
entirety.   It is a deception throughout.
   The senses give  to the mind, sights, sounds, smells 
50
MENTAL diseases.
and  various  other sensations which have no real
existence.  It is  more correct to  say that the mind
misinterprets  the supposed evidences  presented by
the senses of the external  world.  The  objective is
not transformed  subjectively into true  ideation,  as
there is truly  nothing objective.   Those  which exist
from  some perversion in the  organs of  sense, or in
partial congestion of the brain, or  from meningitis,
or from  toxic agents, must not be  confounded with
the hallucinations of the insane.  We  find illusions,
hallucinations and delusions as phenomena associated
also with sane and nervous disorders, such as mania-a-
potu, epilepsy, hysteria, catalepsy, neurasthenia and
such like.
  In  passing, it is worthy of note,  that  in the sane
the hallucinations of sight are more frequent  than
those of hearing, but in the insane the converse  is true.
  Shakespeare has dramatically illustrated this fact
when Macbeth sees the dagger.  Also in " Hamlet "
when the prince  sees his father, the king.
  Nicolai, the bookseller  of  Berlin, by  holding his
breath and thereby  producing temporary brain con-
gestion, could conjure up to himself vision as distinctly
as in real life a goodly company of persons, and could
describe the dress of  each.
  Napoleon  saw  his star  of destiny,  but he was
epileptic.  Castlereagh  saw a  child at his hearth, time
and again.
  Lincoln, at critical  periods in his  eventful life, saw
a sailing ship. 
a delusion.
51
  Sir Walter  Scott  saw at  times  phantoms  of  the
dead Byron.
  Malebranche,  the  metaphysician, often  heard  the
voice of God calling  to him.
  Descartes, also  a great  philosopher, states  that
after long confinement and  study he felt he was fol-
lowed  by an  invisible person urging  him to search
for truth.
  Dr.  Jonson (rare Ben)  says  he  often  heard his
dead mother calling him.
  Byron asserts he was sometimes  visited by appari-
tions in various  guises.  He was an epileptic.
  Goethe declares he saw a counterpart of himself at
various times  coming towards him.   He could conjure
up  at will ocular spectra.
  History  is  full of such examples.   Most of those
cited were doubtless produced because of blood con-
gestion in  the brain, or nervous exhaustion through
mental worry or overwork ;  in short, mind stress.
   Each of us has false perceptions at times, such as
seeing motes in  the  air, ringing in the ears, phosphor-
ence;  seeing  objects  apparently  moving  when we
ourselves are  travelling  onward in a rail-car or in  a
boat, seeing a square tower as  if  round in  the dis-
tance, or seeing a straight  rod  as if  crooked  when
immersed in water; all are illusions of the sane.
   If we imagine we see certain distant objects, especi-  '
ally if we expect to see  them, our  imagination  often
produces an  impression  almost as real as  if  they
existed.  The sane experience and  judgment correct 
52
MENTAL DISEASES.
these false impressions.  A hallucination is, properly
speaking, a sensation supposed to be received through
the senses, but without an  object.
  It is well to state that there  are three theories in
respect to hallucinations and their primary cause.
  1st.  The mental theory, which centres this condition
in the  mind only as a false ideal.
  2nd. The physical  theory, which constitutes them
merely organic phenomena, and  produce false impres-
sions upon the mind thereby.
  3rd,  A psycho-sensorial  theory,  in  which there is
supposed to exist derangement or want of co-ordina-
tion between mind and body.
  The  last of these views is the one  most generally
held to  be  correct, largely because of the fact that
certain forms of insanity with illusions and hallucina-
tions are found to exist with specific diseased condi-
tions in the specialized sensory centres.

                    Illusions.
  An  illusion is an error  of perception.  It is the
transformation in the  mind of  an  unreal perception,
and the  imagining that a real object is partially or
wholly something else.   An illusion is partly true, as it
has a substratum of reality to suggest the error and to
build the ideal upon it.  In  short, it is a false apprecia-
tion of a real sensation.
  It is not to be  forgotten that  both sane and insane
may have illusions arising from disorder of the senses,
and both classes may  form errors of judgment upon 
A DELUSION.                  53
data directly derived from the evidence of the senses.
Let me emphasize the  Tact by repeating that an illu-
sion is a mental conversion of something really per-
ceived, into something that  is  not perceived.   For
example, if one should suppose  that the table before
me is an elephant, or should  imagine  that the street
cars which we  now hear are  making  the  noise of
cannon,  he mentally  converts  something  real (the
table or street car noise) into  something unreal ; that
is, into the elephant or cannon's roar.
   If  these hallucinations or illusions  are believed in
then are they delusive  ; but if not believed in they are
non-delusive, so we may have the two classes of defects.
   Many forms of insanity have unchanging delusions,
and become diagnostic.    They  are called by the
German  alienists primordial delusions.   All  such
may yet be found to exist with definite pathological
conditions peculiar to  each.
   The following points in the clinical history of the
insane are worth noting and  remembering in connec-
tion with delusions :
   1st. To  be  sure  that in insane  cases  there is no
disease in the organs of special sense.  If  there is,
then is it possible to give a wrong diagnosis in respect
to the existence of illusions and hallucination.
   2nd.  When  recovery takes  place  it  is  seen that
delusions and hallucinations chronologically take there
departure together.
   3rd. False lines of thought or dominant delusions 
54
MENTAL DISEASES.
give  character  and direction  to the  hallucinations
when they exist.
   4th. In the failure  of  mental activity  such as is
seen in semi-dementia, hallucinations and illusions do
not usually exist, and if  they do they are of a mild
form and often of a fugitive nature.
   5th.  Fixed  delusions  of a pronounced kind  are
often seen in that unbalanced,  mental activity which
is named chronic mania, or in insane melancholia.
   6th. Entirely deaf and blind  persons have hallu-
cinations of sight and hearing, when insane.
   7th. Hallucinations  of  sight are prominent in the
dark as well as in the light.
   8th. In the acute stages of insanity, in  any of the
forms in which it presents itself, the mental changes
are accompanied by corresponding variations in the
illusions  and hallucinations.   This  gives  additional
proof of their mental origin.
   9th. As  has  been well said by some writer, the
hallucinations of the insane  are not simply vague
sounds, or words, or lights, or ghostly shadows flitting
about.   They are complex and varied, and  often con-
sisting in seeing and talking with people in long con-
versations.   They are often like a reverie  intensified
or personated.
   10th. In all  these delusional states there must of
necessity be complexity  in mental  make-up and  in
physical  manifestation, such  as change  of conduct,
depreciated  mental and moral vigor, morbid fancies,
and it may be largely organic life, as is seen in semi-
dementia. 
A DELUSION.
55
                     Impulse.

  This is a term that contains  no correct idea of a
phase of  insanity, if  taken alone.  It is often taken
and used to describe a  sane  act, such as impulsive
suicide, or impulsive  homicide.
  To shield a culprit these terms are adroitly changed
into the form of suicidal impulse or homicidal im-
pulse.  These are insane acts and the  latter state-
ments mean irresponsibility in the actor.
  Impulse is an unfortunate word in this  relation,
and  has  been used with effect  in  legal courts.   If
insanity  be a disease it  cannot  begin and end in an
impulsive act any  more  than could  hydrophobia  or
typhoid fever.   It must  have time for invasion, pro-
gress, and termination of longer or shorter duration
as all other diseases exhibit.
  Insanity  may  and  often does begin  with  an
impulse,  but it  will  not end with that.  In insane
impulse,  as  in acute mania, there must exist more  or
less disorder of  thought.  We often see motiveless or
purposeless homicide come on   suddenly and  then
followed by delusional mania or dementia, or it may
be, one may be a sequel  of the other, if  it assumes a
chronic form.
  Impulsions are  divided  into besetting impulses
(obsessions) and reflex impulses (impulsions, so-called),
according as they act with or without resistance on
the part of the individual.   They are  also  divided
into  intellectual,  emotional  or  motor  impulsions,
according to the sphere affected.  (Regis). 
56
mental diseases.
               CHAPTER  VI.

                  THE MANIAS.
You will notice in your  text-books on the different
forms of mental disease, how many, in the  one desig-
nation or another, have the  word mania attached to
a term  which is supposed  to be  distinctive of  the
various  manifestations.
  Take, for example, the word monomania, to which
different authors attach different meanings.  Esquirol
states it to consist of mental disorder in which  are
expansive delusions of an egotistic nature.   This  is a
very narrow definition.
  Dr. Bucknill says, to the contrary, that monomania
is secondary to some  other  form of insanity, and is
usually  a sequel to melancholia and means depression
of spirits.  This definition is diametrically opposite
to that of  Esquirol.   Blandford  holds  that  it is
simply chronic insanity, free from extremes.  Mania
and  monomania  are  virtually  used  synonymously.
Clouston  gives  it the  euphonious term  of  mono-
psychosis, which means not simply that there is  one
dominant idea in the  mind  controlling action.  It is
the  neurosis springing  out  of  hereditary  predis-
position, accompanied by lack of  trophic power,  and
as a consequence brain  anaemia.  The records show
that a large number of such die of latent phthisis. 
THE  MANIAS.
57
  Bucknill and  Tuke  truthfully say : " We heartily
wish  monomania  had  never  been introduced  into
psychological  nosology, for, if understood in a literal
sense, its very existence is disputed, and if not, the
various morbid mental conditions it is made to include
by different writers lead to hopeless confusion. With
one author it means only a fixed  morbid idea; with
another,  only partial cxtdtation,  while  a  third re-
stricts it to a single morbid impulse."  The list of
authors with  different definitions might be extended
almost indefinitely.  Some author saj^s that  it simply
means a, fragmentary  mania, or insanity, on a single
topic.  There is now a tendency to give a new name
to the condition of so-called monomania, when the
dominant ideas  are  egotistic exaltation coupled with
persecution.   The term is paranoia, of which I will
have more  to  say hereafter.
  The term " partial  insanity" or " temporary  in-
sanity "  has no clinical conditions to correspond to
one or the  other.  To give a distinct term to only one
prominent  feature of  mental disorder  is misleading,
but to twist a word out of its world-wide interpreta-
tion is likely to  lead to error in diagnosis.  We might
put the monomaniacal group in juxtaposition, thus :
                    Monomania.
             Klepto-
             Pyro-
             Eroto-              Mania.
             Homicidal
             Suicidal 
58              MENTAL  DISEASES.
   The homicidal monomaniac has only a tendency to
kill another, arising out of a substratal general disease
based on delusions or merely springing out of impulse.
Yet, he is usually quiet and orderly, except in the one
lethal act.  He cannot justly be called a  maniac, as
there is no general excitement of a continuous nature.
The  true maniac never  plots  injury to  himself or
others, except by misadventure.  He is centred all in
self.
   The  pyromaniac may coolly, deliberately and cun-
ningly burn houses and barns, yet give no evidence of
maniacal  furor  from  beginning  to end of his acts.
His hankering to do this form of destruction never
leads him to show excitement of any form.
   The  kleptomaniac steals useless  things or one set
of articles only, in which is no  advantage to him ; or
useful  things  which are never  utilized  nor disposed
of for gain or  profit, without one moment of  mental
perturbation  from first to  last.   The morbid desire
to simply possess  is  given  way to without let or
hindrance; but there is no sign in  language or con-
duct to indicate mania.  So I might go on describing
these so-called partial maniacs in which are no excite-
ments,  and to which the generic name of monomania
is not applicable.
  I read the other day a work on this subject in which
the author had the usual  craze for an infinitesimal
nomenclature.  He called the  "insane desire to marry"
by the classic  term of " gamomania."  This  has been
endemic  since the  days  of Adam  and  Eve, and is 
THE  MANIAS.
59
likely to continue until the final consummation of all
things.
  The other day a German designated " the mania to
steal women's shoes/' Frauen Schulstehl.
  I might be permitted to add to such  absurd dis-
tinctions, by calling  erotic desire in a woman mano-
mania.   My newly coined term  would at least  be
clinically correct in part if not in its entirety.
  The word mania being attached to so  many terms
leads to serious error in  jurisprudence,  and teaches
the public, from which are drawn our juries, to believe
that an  insane person must of  necessity be a maniac.
  When the quiet, delusional and homicidal lunatic is
tried for murder or attempted  killing, his  manner is
so orderly  in prison or in the dock  that no wonder
ordinary men, to  many  of whom a lunatic  is a curio-
sity, think that such a well-behaved man must be sane
and responsible, and he is hanged accordingly.
  They do not  know that the typical maniac does not
belong to this class, and that "raving madness" is not
very prevalent, even in hospitals for the insane.
  Some such term as " Impulsive Insanity " would be
more appropriate  in describing the so-called mono-
maniac.  Those thus  afflicted  manifest  the morbid
mental  bias  through varied  impulses—some  of  one
kind, and some of another—yet, the diseased con-
dition of the brain might be largely uniform in all.
It is not to be supposed  that each of the monomanias,
or each  of the general manias, or, in fact, any  one
of the myriad  forms of  insanity, with isolated signs 
60
MENTAL DISEASES.
and  symptoms,  has recognizable pathological con-
ditions  peculiar  to each  as  exciting  causes.   The
least molecular disturbance, the lowering of  organic
life  without disease, simple anaemia or hyperaemia,
or the cell-world  in our nerve centres in sluggish
conditions may and does bring to the surface latent
traits of character without supposing  peculiar  and
distinctive brain changes to correspond to each mental
condition. The same may be said in respect to diseased
changes  of  a  gross nature.   We have  being made
manifest the trend of individual minds in the so-called
monomanias without the  discovery of  any  specific
form of disintegration which could be labelled.  Until
such is found to be the case it is well  not to divide and
subdivide mere symptoms, and attach to each phenome-
non a name  which has no clinical significance.
  Even the word mania must be taken in  a circum-
scribed  sense as  it enters into other forms of insanity
not thus designated.  We find mania a prominent
feature  in intense melancholy.  Excitement is often
present in a dementia  which is not profound.  Par-
esis,  in  its  early stages,  shows  pronounced  mania.
Epilepsy is scarcely without it of the severe kind.   It
is  often  an  element in syphilitic  insanity and the
paranoiac with  strong  delusions of  persecution may
become insanely excited, goaded thereto by his false
ideas.
  It is evident, then, that the term mania in its widest
sense cannot constitute  a distinct class  of the insane.
There is, so  to speak, a correlation of mental  energy 
THE  MANIAS.
61
in many of the forms  of  mental alienation.   These
translations are seen in the dominant and imperative
impulses.   This metamorphosis of one outbreak into
another is often seen in so-called homicidal and suicidal
mania, pyromania, kleptomania and narcomania.  All
these manias have comtnon characteristics, but change
according to the mental and physical idiosyncracies of
each individual.   The  inhibitory  power is weakened.
In other words, the  balance-wheel  which  regulates
the motion of  the volitional centre is out of  gear, and
the moral  nature  is blunted, which so often controls
conduct.  As  Ribot, on " Diseases of the Will," puts
it, " They are conscious, inco-ordinated and  incapable
of struggle."
                  Mania Proper.
   It has been my custom heretofore to classify the
general manias into two great groups,  viz., sthenic
mania  and asthenic mania.  In this respect I was
following the  plan of well-known authors.
   In thinking the matter over I have felt  that  the
word sthenic (or strong) was virtually a misnomer, as
the manifested strength was a call upon the reserve
force and was  really an evidence of weakness.  This
fact is seen in  other diseases.  Clonic and tonic spasm
is evidence of  weakness, although there is  exhibited
great power for the time.   The same might be said
of the strength put forth in delirium tremens, in the
delirium of fever, or in the temporary power  given
to men under the stimulus of various excitants,  yet 
62
MENTAL DISEASES.
we know that a proportionate equivalent of weakness
must follow.
  The maniac is generally credited with possessing
an absolutely large  amount  of physical power, and
although one is now and again  astonished at some
feat  of  unusual  strength, yet it is at  the expense  of
latent power.  The singleness of purpose of the delu-
sional maniac gives  intensity and force to the acts;
the  same is seen, for example, in the prodigies  of
physical energy performed by  soldiers or sailors  in
the excitement of a battle.
  The maniac  is  not physically stronger than the
sane, yet  the power  of endurance in many of this
class is simply astonishing.
  A  weak woman, for  example,  will, day after day
and night after night, talk, walk and gesticulate, and
at the same  time take little nourishment.
  This state of excitement  may  with  intervals  con-
tinue for months  together, yet during  such a  period
there is little abatement of  physical  strength.  No
sane  person could do  this without dangerous exhaus-
tion  ensuing.
  In a general way, insane mania  may be said to  be
« physical affection, characterized by unusual mental
activity with partial  or complete  incoherence, accom-
panied  by  bodily excitement  not normal  to  the
individual,  and for which  there is  no  rational
cause.
  In the acute stage we have usually presented (a)
physical agitation, (b) mental perturbation of an exalted 
THE MANIAS.
63
kind, (c) inhibitory powers for the time inert  or  par-
tially so.  There  is no  mental lever to regulate  the
power.  ((/)  Consciousness, memory and coherence of
speech absent.  Any one  thus afflicted is a  typical
case.
  This form of frenzy very often  comes on suddenly
and sometimes runs a rapid course to  death.   When
we  have  in  addition  to the  above  symptoms an
increase of temperature, muscular wasting, wiry pulse,
refusal  of food, sordes gathering about  the  teeth, a
brown, dry tongue, clammy sweat, tympanitis, short-
ness of breath, perpetual motion, involuntary urina-
tion and foecal discharge, twitching of  the  tendons
and  muscles  and persistent insomnia,  then we know
that death, possibl}' sudden death, is imminent.
  So like typhoid  fever in its latter  stages is this
acute form of mania that many authors give it  the
name of typhomania.
  I repeat, it is well to remember in this connection, as
well as in other forms of insane mental  exaltation, not
to use the word delirium as being synonymous with
mania.  The former word properly belongs to and
designates the temporary mental  derangement which
accompanies  bodily  diseases  of an inflammatory or
febrile type, and which  is only symptomatic  of such
diseases in a  subsidiary  way.   This is  an  important
distinction which it may be well  to keep in mind; at
the same  time, it is right  to  know  that  continental
writers often hold the two terms  to  be synonymous.
This is a serious error in nomenclature and in clinics. 
64
MENTAL DISEASES.
as  the  two  conditions  are  symptomatically  quite
distinct.
   The following points are noticeable in acute mania :
   1st. It  usually begins  with a period of  depression
of longer  or  shorter duration,  and usually two  or
three weeks in duration.
   2nd.  Its time of invasion in a majority  of  cases is
from  three to  five months, in some, however, it lasts
for a  year and more.
   3rd. When  recovery sets  in it is often very rapid,
from  a few days to about two weeks.
   4th. The more intense the attack, as a rule, the
shorter  it is.  " The  hotter  the tire,  the   sooner  it
burns out."
   5th. A sudden attack of mania of an intense type,
bordering on what  might be called frenzy, will often  ^
as suddenly disappear.   Such cases are more apt to
have relapses than are those who have invasions of a
more  gradual kind and whose convalescence is equally
slow.
   6th. As a general  rule the mental disease which
comes on slowly goes away slowly.  There is  less
danger of a relapse in such cases unless it is only a
phase in circular insanity.
   7th. As a rule, asylum  statistics show a preponder-
ance of  cases on the female side.
   The fact that woman are more nervous than men
and more  emotional may be factors.   It is not to be
forgotten that  the puerperal state is often a cause.
  tfth. A  mania  often  terminates on  the invasion 
THE  MANIAS.
65
of some  other  disease, as if  two such diseased con-
ditions could not exist cotemporaneously.  An attack
of pneumonia,  of inflammatory rheumatism, of diar-
rhoea and such like are examples of conditions which
seem to modify if not extinguish a mania.
  9th. The return of  health is usually seen in mental
oscillations,  as it  were, of the psychic pendulum, and
not  in  a continuous  and  progressive  improvement
without drawbacks.   It is like an incoming  tide with
its ebbs  and flows, but with the trend  upwards  and
inwards of  each successive wave.
   10th. Mania attacks the patient  with abnormality
in the  mental mechanism.   Sensation, ideation,  per-
ception,  memory, volition and judgment are out of
balance, and hence lack of  mental co-ordination.
   In chronic mania we have all degrees of  intensity,
from the most  pronounced to the mildest type, many
of these live to a good old age, as the excitement is
not  sufficent to drain to an appreciable extent the life
forces.   Many of the least excitable  are  useful in
doing ordinary work about asylums.
   It is  difficult to give of this class an epitome of the
symptoms in detail, except  in a general way.   There
is more variety in  the manifestations of a  disease so
pronounced as  mania than  in the negative symptoms
of dementia, or in the quiet and  often  unobtrusive
conduct of these afflicted  with  insane melancholia.
The trend of a varied mentality is most plainly seen
in mania, and  as in  all  diseases the  idiosyncrasies of 
66
MENTAL DISEASES.
each  individual come  to  the  front and show native
diversity.
   In  chronic mania the furious maniac is seldom seen ;
although, in past ages  writers tell us they were very
common.  In fact, the word maniac was held to mean
a raving madness or a frenzy.
   The comparative  quietness in our  large hospitals
for the insane is mostly due  to little or no restraint,
to personal kindness and the absence of brutalizing
and degrading methods in their treatment.   Madness
under aggravation was not  always a  necessary pro-
duct of  the malady,  but was  a result of unnecessary
restraint and mismanagement.
   Chief officers of asylums  have brought to  them
ever and anon patients who are violent and boisterous
because they are in irons or tied with ropes and straps
by friends and relations, based upon the mistaken idea
that to be insane necessarily means  to be dangerous.
At the asylum door  these are removed and, as a rule,
the result is comparative  mildness,  quietness and
tractability.
   The animal instincts rebel against restraint.  This
is  strikingly  true should the  mania be of the  delu-
sional type.   The insane patient will naturally mingle
the realities of  the treatment to which he is subjected
with  his  delusions and  suspicions and  fears.  If a
patient imagines himself to be in some place of tor-
ment, or is about to be murdered by his persecutors,
who are standing around him, he  is apt to have these
morbid ideas  intensified if he is treated badly.  The 
THE  MANIAS.
67
lowest natures, sane or insane, animal or man, appre-
ciate kindness and almost intuitively know friends.
  Many of these chronics are filthy in their  habits,
and some of them even beastly.  Numbers of this class
will  not even  obey the  calls of  nature.  Some  of
them will, every night, besmear their bedrooms with
their own tilth as well as their persons, and will even
drink their own urine.  This general mania is not, as a
rule, apt to lead to dangerous acts, and, in the chronic
form, is often manifested  in a childish disposition
more than in any maliciousness.  The rule is, that we
find  blunted sensibility, but  occasionally there is, in
the  sensory  sphere,  hyperaesthesia.   The senses  of
smell and taste are  often  deficient  in  sensitiveness,
but sometimes very acute.
   Unless this class is  bordering on dementia  there is
a good  deal  of intelligence left, and, if the mania is
of a mild type, such are very  good workers.  Our
insane gardeners, farmers, tradesmen and mechanics
are  indispensable as helps in the varied occupations
which are carried on  in asylums.
   Acute mania is a form of insanity often simulated
by  imposters.  The  sham  is  easily  detected.  No
amateur lunatic can  readily put on the wild,  restless
eye, the ceaseless movement, throw together  the dis-
jointed ideas and  use the rapid utterance of acute
mania as the insane do.  In  acute mania the skin is,
as a rule, dry and harsh, or  cool  and  clammy.  The
malingerer, who lashes himself into fury, on account
of his exertion is hot and sweating.  The maniac will 
68               MENTAL DISEASES.

pass days without sleep, and even weeks with only a
few hours at a time.   No imposter can do that, nor
can  he  keep up  the  excitement  for  a  lengthened
period.  A pretender not  well skilled in the different
forms of insanity will  mix  them up.  He is a  poor
actor ; and if hints are given of his inconsistencies in
his acting in his presence, it is astonishing how readily
the bait is swallowed  and the incidental hints acted
upon.  No insane man will care about hints or advice.
  The deceiver  succeeds better in simulating chronic
mania.  In  this he overdoes  the  signs, and, in his
eagerness to appear insane, he oversteps  the bounds
of insanity  and  overshoots the  mark.  He usually
thinks a lunatic  must constantly gesticulate, bellow,
rant and  rave,  and therefore indulges in gross exag-
geration.  He  pretends that  he has no memory of
anything, and puts on foolishness and stupidity.  The
really insane with chronic mania, if not an imbecile
or an idiot, is not so deficient of  mental power.   Few
will  pretend to be  insane unless to excite pity  or to
escape punishment for crime, or to avoid heavy labour
in prison.   A few  such  deceivers  have come  to us
from the Central  Prison to  avoid work, or to have a
better opportunity  to  escape, or to have, as one of
them said, " a  good  time,  with plenty to eat  and
nothing to do." 
DEMENTIA.
69
                  CHAPTER  VII.


                     DEMENTIA.
  Dementia is the lowest form of insane intellectuality.
  In short, it is mental decay because of brain degenera-
  tion.  It effects every mental faculty, and is stamped
  upon and is patent in the intellect, disposition, habits,
  manners, temper and  general character of  the  indi-
  vidual.   It is  mental deprivation, and  is contra-dis-
  tinguished from the mental exaltation of mania,
     Dementia is usually classified under  five kinds:—
     1st. Primary  dementia  is the  result of deficient
  brain development.   This  is  not insane dementia-
  We see  it illustrated in idiocy, congenital imbecility
  and  cretinism.  It  is  not  to  be  forgotten  that in
  amentia we  have simply  want of  growth of brain
  cells, hence circumscribed mind growth.  This is not
  mental atrophy from a higher developed condition and
  pathological;  it is mind deprivation from  physiolo-
  gical failure in growth and activity.   The instrument
  is circumscribed, so must be the agent's power which
  operates upon it.
     2nd. Secondary dementia, as a sequent of other dis-
  eases, may be centric or eccentric.
I     3rd.  Senile dementia.  This is not only the natural
  decay of old age,  but  includes  premature natural 
70               MENTAL DISEASES.
decay, which often begins at the second trial epoch of
life in many, because of a life of mind stress, or it
may be  handicapped by  a bequeathment of malign
tendency which precipitates mental degeneracy early
in life, should the conditions be favourable.
  4th. Organic dementia.   Under this head is classed
those who are thus afflicted as a result of gross organic
or traumatic injury to the brain.
  5th, Toxic dementia, following the  undue  use of
alcohol, opium and its salts, and  such  like,  including
the long use, in large doses, of the iodides and bro-
mides.  In such, childishness  often supervenes early
in life.
  Strictly stated, dementia is  a term which should be
used only in referring to physical disease which pro-
duces thereby  acquired mental  enfeeblement,  while
imbecility should be a term applied to mental weak-
ness, based upon congenital, foetal or infantile  arrest
of development,
   The moral faculties being based upon, and spring-
ing out of intelligence, must of necessity be absent in
this class of the insane.
   The changes are often seen after attacks of apoplexy,
of paralysis, or of continued alcoholism.
   We see  in typical cases of dementia a  change of
physiognomy.  The countenance becomes expression-
less.  In extreme cases the eyes have a vacant stare.
There is a silly smile on the countenance, or more
often meaningless apathy.  In short, the silliness, the
stupidity,  the  relaxation of  facial muscles, the list- 
DEMENTIA.
71
lessness,  the  hanging head and  dangling arms, the
lolling about in  an aimless way, the altered expres-
sions  of  countenance, the  puffy  hands and feet are
appearances when once seen are not soon forgotten.
  When  such are addressed, they may raise their eyes
and look out at the corners of  them, but they will
seldom raise the head.   They  would  burn before  a
fire before they  would move.   In summer, flies will
settle on the eyes of a dement or  round his nose and
mouth, but their tittillation will not disturb his stoli-
dity and apathy.   The saliva and secretions from
mouth and  nose are unheeded.    The urine and faeces
pass involuntary as in early childhood.   In the lowest
forms such would neither eat nor  drink.  The natural
cravings of hunger and thirst are at a  low ebb.  The
same may be said of endurance to pain.   The face is
often  purple, and the skin and hair become harsh and
dry.  The perceptive faculty is faint.  The emotional
nature is blunted.   The sexual instincts are weakened
or destroyed.  Memory, attention, logical sequence and
knowledge gained from experience have little or no
existence.  The above  description is that of  a  pro-
found case of dementia.   There are  all gradations of
this class up to those  who are merely childish, but
have sufficient intelligence to  be usefully employed.
To this class I apply the term semi-dementia.
  Secondary dementia has some other  form of insan-
ity preceding it, such as mania, melancholia, paresis,
and some of the fleeting forms  of delusional insanity.
  This form may be a direct sequel to  other forms of 
72
MENTAL DISEASES.
   insanity and there may be periods  of  slight mental
«   brightness  interjected  into  its course which would
   look like partial recovery; this temporary waking-
   up from mental lethargy may be followed by a stage
   of confusional ideas, and then comes a lapse again into
   the chronic condition.  It is usual with some writers
   of psychiatry to call this  transition stage tertiary-
   dementia.  In fact, it is not a different form, but is
   only a temporary waking-up of mentality under that
   rhythmic  law  of periodicity  which  is  seen  to a
   greater or less extent in all diseases.
     In  the profound forms of dementia  there is  more
   or less loss of common sensibility.   Sometimes  there
   is the loss of the  use of one of the special senses.
   Sense-loss always means to  some extent  mind-loss,
   as the special senses  are avenues  of  knowledge of
   the external world  from whence our  primary ideas
   are suggested and  generated.  This statement  does
   not  absolutely  hold good  in  the  deprivation  of
   recollections  or  retrospects   of  the  past.  Loss  of
   memory alone  is  not  an  infallible test  of mental
   dethronement or even weakness of intellect.  Many
   imbeciles have a wonderfully retentive memory, and,
   for example, show great capacity in  arithmetical cal-
   culation.   The imbecile, blind Tom, had a phenomenal
   recollection  of  musical notes never heard by  him
   before in  the new  and  unlooked for relations and
   combinations of  harmony and melody.   Some  one
   faculty of the mind seems to not only tower above its
   fellows, but also to dwarf them in their development. 
DEMENTIA.
73
The human  mind seems to be  like a  reservoir with
many out-flowing rivulets.  The complete or partial
stoppage of a few of these gives more  force  and im-
petuosity to that which is  unimpeded.  We see this
rule in so many sons of genius who are great in some
art, but  whose  biographies show them to  be very
small, indeed, in every other direction.
  As a rule, because of incapacity to be taught, added
to want of judgment, the  imbecile prodigies are
useless as citizens, except  to  be exhibited  at dime
museums.  Insane  semi-dements  often  show  great
ingenuity and originality in some one direction, and
are foolish  withal.  Those  who  have  learned  trades
and thereby have  acquired manual  dexterity need
little  mentality to carry  on the  same occupation.
Many of the  movements  become purely mechanical
because of repetition, and the mind itself in the same
direction becomes automatic.   Our insane gardeners,
tailors, shoemakers, carpenters and  blacksmiths come
largely from among our semi-dements.
  These are very useful patients.  Many of them are
more  or  less intelligent.  Some have harmless delu-
sions  which, when pleasant, beguile the hours away
as they are  facts to them, even if this mental pano-
rama is a building of castles in the air.
  Organic  life is seemingly in  a  good state, hence
excellent bodily health.   They  eat well, sleep well,
work  well, and are generally contented with their
lot. They are usually gentle in manners and  obedient
in doing  any work  assigned to  them.   At times one 
74
MENTAL DISEASES,
or another may, for a day or two, become intractable,
because of  some  delusion  becoming  dominant,  but
this state passes away in time and all is well again.
  They have, as  it were, children's minds  in  adult
bodies.  The  vegetative functions  are apparently
normal and the nerve centre of the mind has in its
abnormality assumed   a physiological  habit, as  it
were;  and  if  an  Irish  bull is permissible,  becomes
normal in its abnormality, just as we find in a scar,
in the callus  of a once broken bone, or in the life-time
adhesions  of pleurisy.  The  brain  degeneracy  has
come  to a  standstill and  as a result  the  mind  has
returned to a permanent state of childishness.
  We  find,  however,  that  such  easily succumb  to
diseases of  an inflammatory nature.   The healthful
appearances  are often deceptive and we see the want
of tone and  the  low  recuperative  power when  the
system is put to the test from the drainage which any
active  and  aggressive disease  makes on its vitality.
The reserves are few and easily exhausted and disin-
tegrated in  the sustained and  continuous battle  for
life against these  inroads.
  We are also to  be guarded not to confound natural
failure of  memory with diseased conditions  such as
the insane dements show.
  Esquirol included idiocy in the term dementia. The
distinction  between the two classes is radical.   The
nascent state and  the acquired ; the want of develop-
ment on the one hand and the loss of acquired mental
faculties on the other  make a line of demarcation so 
DEMENTIA.
75
plain as not  to be  misunderstood.   Jurisprudence
extends the meaning to all classes of persons afflicted
with  mental weakness, as its standard is simply that
of  mind-loss  irrespective  of  causes  and   physical
states.   In law it is merely mental capacity which is
considered. It is the citizen, not the patient, that law
considers in its estimate of responsibility.
   The child of  immature age, the idiot, the imbecile
and the dement are held to be  incapable to discharge
an obligation, and are, therefore, not accountable  for
their actions. 
76
MENTAL DISEASES,
CHAPTER VIII.
          GENERAL PROGRESSIVE PARESIS
                  (GENERAL PARALYSIS).
  This is primarily a brain disease in the cortical areas.
  As it progresses, the diseased condition spreads until
  all the  nervous system  is  involved, including the
  spinal cord and the  sympathetic.  Its invasion is not
  always uniform, although  the mental symptoms are
  usually  first  noticed,  especially in  superabundant
  egotism and erratic conduct not natural to the patient.
]  He has  a  recklessness  in  respects to plans and the
!  spending of money  in speculations  generally  dis-
  astrous because lacking in judgment.  He becomes
  silly, impulsive and restless; and, although abstemious,
  may  be thought to be under the influence  of liquor.
  Then may follow a change in articulation.   It is not
  such  as we hear in  hesitation or stammering.   It is
  simply as if the tongue were  too big  for the mouth ;
  in short, it is lack of co-ordination, and means partial
  loss of control over the vocal  organs.  At first the
  change is very slight, and might not be noticed by an
  ordinary observer.   After a time, he  may speak dis-
  tinctly at first, but if  the  conversation should be
  prolonged  his  control becomes impaired.   In the
  incubative stage, when  such  come under the  notice 
GENERAL PROGRESSIVE  PARESIS.        77
of the  medical man, he  may be  deceived  by  the
apparent physical health of the patient.  His appetite
is  good, and it may be  ravenous; he  has splendid !
digestion; he  complains of no pains, not  even head-
ache ; he sleeps soundly; he  feels well, and any en-
quiry in that direction is usually answered by such j
expressions  as " I feel  first rate " ;  or, " I  never  felt
better in my life."  The physical  activity shows that
mere organic  or vegetative life  is  so  far little  im-
paired.   The friends, however, will tell of the change
of  natural  mental  characteristics, notwithstanding
these evidences of  physical  health.  There crop up  j
irregularity of  temper, transitory defects of  mind,
especially of intellect; lack of  judgment and discretion
in following his usual occupation, and moral perversion
in untruthfulness and in gross venereal excesses which
may surprise  his friends  who may have known him
through life as a model of propriety and religiosity.
Intellect and morals are being dethroned. The general
practitioner too often  overlooks  these  premonitions,
which  are truly pathognomic, and often  in certificates
of insanity  call this distinctive  disease " mania," or
" delusional  insanity," or " dementia."   Any of these
may exist, but they are only symptoms of this under-
lying general condition.
   It is  not to  be  forgotten  that  we  often have the
prominent physical symptoms appearing first, and at
the same time may not be able to detect any mental
trouble.  In my experience, as   a  rule, the mental
deterioration antedates the physical, but often  both 
78
MENTAL DISEASES.
are coexistent in  the initiatory stages of the disease.
Being a disease  of the higher  nerve centres, it is
evident that  much must depend on the  resisting
power of those  nerve  masses in  detail as  well  as
combined, hence the variety of phenomena presented
in respect to the invasion of the disease. The general
depreciation of co-ordination is very  marked as  the
disease advances.   The lips are tremulous, such as we
see in a child about to weep.  There is often grinding
of the teeth  in the last stage;  when  the  tongue is
held out it trembles and is often  drawn  slightly to
one side.  It requires an effort  to protrude it.
  Irregularity in the size  of one pupil  compared
with the other is well marked in  most cases, others
have  simply enlarged  pupils.   The  patient has a
shuffling gait and a relaxation of the muscle of  the
legs, such  as we  see in persons walking on slippery
places and who are not sure  of their footing.   He
does not drag his  feet nor bring  them  down with
a clatter as is seen in  locomotor ataxia.   It is not
so much want of muscular power, although that is
somewhat  deficient,  as  want of  directing  energy.
The same is  true of his prehensile power and feeble
direction,  as is seen in the attempt  to pick up a grain
or a needle.
  In these respects it is distinct from true  paralysis,
in which  sensation and motion  are  last.   The  last
organized centres fail first.  As  a  result the  higher
mental powers, as well as the  more recenth* educated
physical acquirements, are  the first to show signs of 
GENERAL PROGRESSIVE PARESIS.         79
decay and to throw out signals of distress.  Hence we
have weak memory, feeble concentration of thought,
flagging attention, lack of judgment, erratic conduct,
wild  imaginings,  muscular enfeeblement  and  inco-
ordination, primarily seen in  the  last acquired dex-
terity through handicrafts.
  At the early stage of the disease the mental symp-
toms are usually well marked.  Occasionally  he may
be melancholy, but ninety-nine out of  every hundred
are full  of hope and cheerfulness.   Self-pride and
self-praise are prominent.  Although poor, the paretic
may, in his imagination, think himself to  be a man
of  immense wealth.  Millions of dollars  are at  his
command.   He owns kingdoms  and can dethrone
monarchs at will.   He bestows favors lavishly, in his
own mind.  He has  plans of all  kinds, which show,
to him, such gigantic wisdom and intellection which,
when made known, will  astonish the world.  No man
can compare with him in the vast grasp of his  mind
or the grandeur of his diverse schemes.  The  asylum
may be his palace,  and every person in it his slave or
his most obedient  servant.   His grandiose ideas  are
many, and enter into the warp and woof of his  daily
life, giving colour to all his tangled strands of thinking.
In short, his panoramic ideal world  is most pleasing,
in which, with wildest fancy, he is "biggin' castles in
the air."
  All  such delusions may  exist without  paresis, so
the  diagnosis  must  include  the  evidence  of the
distinctive  physical  deterioration.  As  the  disease 
80
MENTAL DISEASES.
progresses  these symptoms intensify until, last stage
of all, he  lapses into dementia;  yet, as  a rule, he
eats  well and sleeps  well  until near the  end.   On
account  of  the partial  throat  paralysis,  when in
this condition, his food, if solid, has to be cut up very
fine for him, else in his bolting of his food  he would
choke himself.  He has to  be  closely watched while
eating.
  Towards the end he loses control of the sphincters,
and becomes very filthy.  Hemiplegia often  sets in,
and remains until death ; but, if the attack comes on
early, he may  partially recover  from it for a time.
  Death  may ensue from mere exhaustion in the great
nerve centres,  or  from  epileptoid or apoplectiform
convulsions  superadded,  and which  precipitate  the
end ;  or  life may be shortened  by  the invasion of
tubercular disease.
  The disease  seldom  lasts longer than four years, and
so far is incurable.  Cures are said to have been made
in pronounced  cases, but the diagnosis is to be doubted.
The  extensive and   profound  pathological changes
which take place in the nerve structures, in  the inter-
stitial substance and in the envelopes are too great to
be restored to health by  any  therapeutic agent  put
into the human stomach.  The same is true  in respect
to the attempts  to relieve  the brain of the  super-
abundant fluid by  trephining, which  some ardent
surgeons have attempted, and with not  very satisfac-
tory results.  It is  true, glowing accounts  have been
given of  the results of these operations ; but, however 
          GENERAL  PROGRESSIVE PARESIS.        81

brilliant the operations may have been, the end was
death.  Tapping the  membranes wall not affect favour-
ably  the  diseased conditions of  all  the  contents  of
the skull and spinal  cord.  Women are not as subject
to this disease as men.  In this asylum the proportion
is one  woman to twenty men.  The statistics of  a
number of  other institutions  give  a much larger
proportion of women, even up  to one in four of the
men.
   Our experience here is, that the better classes of the
community are  afflicted ; those who  have lived well
and  did  not know  what want was.   Our private
wards are never  free from it, on the men's side of the
house.   As  in all  forms  of insanity, the causes  of
paresis are  varied.   Taking  the life-history of each
 patient to  judge from, the  principal causes  seem  to
 be principally four :  (a) syphilis; (b) drunkenness ;
 (c) sexual excesses ;  (d) worry or mental stress.  These
 may be results  in many instances rather than causes.
 The indications  of  the  insidious   invasion  of  the
 disease often  show themselves anterior to the de-
 bauchery,  licentiousness,  and  domestic  or  business
 troubles.  Friends may not  notice this change ; so an
 outburst of strange language and conduct may seem
 to them to be  the  initiatory  stage of  the disease,
 although it riiay antedate this time.
   It has sometimes remissions, and these are often so
 complete as to deceive physicians into  the belief that
 they are recoveries.   In fact, some authors declare them
 to be such, but a disease which never loses its grip of  the 
82
MENTAL DISEASES.
system, and which we know is sure to return sooner or
later, and end fatally, cannot rightly be thus desig-
nated.   I have seen such in the remissions go out and
engage in their usual occupation  from a few months
to a  year and a  half, and act rationally during that
halting period, but at last they  return to  die.   In
many cases, such periods of apparent convalescence
may be often during the course  of  the disease, but
they shorten  in duration as the disease  advances.
Like an outgoing tide the waves may come back upon
the sand, buti each successive wave  fails to reach the
boundary line of its predecessor.   The disease may  be
old, but a correct record of it was  first given  by Bayle
in 1822.  About twenty years ago I came across a
volume of 225 pages written on this form of disease,
by Dr. T. I.  Austin, of Bethnal Asylum, England,  in
1859.  The  diagnosis  is  well pictured, and  on the
whole  correct, and the pathology shows painstaking
research for that day.  As to its cause, he says : "The
wear and tear of modern  society,  the intense and
therefore frequently unsuccessful struggle for position
or livelihood, which  is everywhere going on  around
us, and which is so  characteristic of  our age, and the
more frequent occurrence of mental  anguish ; the
consequence  of  domestic trials,  may have actually
augmented the number of its victims." In striking
contrast to the treatment of the  insane in  this day,
he graphically states that " From parish workhouses,
and  even  from  respectable wealthy homes,  comes
many  a poor, demented  victim of general  paralysis, 
          GENERAL  PROGRESSIVE  PARESIS.        83

with his head shaven, his  nape blistered, with leech-
bites on his temples, and cupping marks on his should-
ers, his wrists and ankles abraded or ulcerated from
restraint, his abdomen discolored from having been
bound  to his bed by a  sheet, emaciated to  the last
degree, his trochanters nearly starting through the
tense, livid skin, with bed-sores over the sacrum and
on the nates, and with the inguinal clefts excoriated
by ammoniacal urine.   He has been neglected by his
domestic attendants, who have probably thought such
an existence was not worth continuing; or he has
been  hurried into dementia and extremity  by the
fervour of his doctor, who  has evidently imagined he
had to deal with an acute and curable disease."  This
dreadful recital was made only thirty-five years ago,
and is  in striking  contrast  to the treatment of the
insane  to-day  in  Christendom.   The  pathology of
progressive   paresis  is  very  distinctive, and in  a
general way the life-history of a paretic could be
outlined, based upon the footprints of  the disease on
the nerve masses.
  There are adhesions of the membranes principally
over the front part  of the brain.  The pia mater is
found  firmly attached to  the brain substance, as if
glued to it.   If the membrane is torn away it leaves  >
a rough depression,  with serrated edges, very much
as we find in a phagaedenic ulcer.  The cause of this
is, that  part of the  brain substance  comes away
strongly attached to the membrane, and leaves these
pits where it is torn away.   These adhesions are very 
84               MENTAL DISEASES.

characteristic, and differ from the usual inflammatory
adhesions, in being attached in  isolated parts.   There
is no evidence of pus or of there having existed active
inflammatory processes.  It is likely that the  morbid
condition proceeds from  the brain to  the membrane,
and not vice versa.  Puncta are very numerous, no
doubt because of the passive congestion which  existed
ante-mortem.
  In short, it may be said to be a chronic non-inflam-
matory process of  deterioration, springing  out of
excessive functional  activity, or from a diseased con-
dition  of  the  blood  vessels specific  or  otherwise.
There  is no doubt a morbid change in the ultimate
elements of  the brain, and this  molecular disturbance
means  defective  metabolism.    Granular  and other
morbid deposits are found  in patches  seemingly pro-
ducts of a low  form  of vitality.  These  adventitious
substances give no evidence of  being tubercular, and
reagents show  they are not of  a  fatty nature, nor
merely inorganic  as seen by the hydrochloric acid
test.   These  granular deposits  seem to  be a kind of
colloid degeneration.
  Sometimes the adhesions of  the dura  mater to the
inner table  of  the skull are so  tenacious that it is
torn away with  difficulty, and sometimes in layers.
The arachnoid is opaque  in patches, and the sac made
by the membranes is abnormally filled  with  a semi-
gelatinous fluid, which is also found in the ventricles.
There is usually brain atrophy and vascular loops in
the capillaries.  The vessels of  the pia mater  are en- 
          GENERAL  PROGRESSIVE  PARESIS.         85

larged and  as  might be  expected that condition  is
seen in the lateral  ventricles where the pia mater
takes the name of the choroid plexus.  Very often
the walls of the arterioles are incrusted with granu-
lations, and the surface of the membranes in patches
present scattered cell granules and extravasated blood
globules.  The brain shrinkage seems to be in the
white substance, for the grey layers seem unchanged
in quantity ; in short, sometimes there is development,
or rather hypertrophy  in  the  interstitial structure,
with vascular tree-like plexuses of arterial vessels.
   One convolution  is not adherent to another, nor
does the pia mater  adhere  to the  brain substance in
the sulci.   The reason may be physiological as it dip
between them purely as a net-work of  blood vessels,
unaccompanied by fibres and lymphatics as is the case
elsewhere.   The  ventricles  are  larger  than  normal,
and occasionally the grey master in places is thinner,
but is more dense.  The  apices of the sulci are not
all on a plain, but  many of them show shrinkage.
The white matter is often  very  much congested  in
patches.
   The morbid processes in the nerve cells may be brief-
ly summarized. The  pyramidal cells in the lower strata
of grey matter are  always affected.   The  ganglion
cells contain nuclei and, if in large numbers, they may
swell the cells out of shape.
   This is not  the rule, for the multipolar cells are
often shrunken, lose their angular appearance and the
caudates disappear.  There  is often in  the brain evi- 
86
MENTAL DISEASES.
 dence of the various forms of pathological change such
 as fatty, pigmentary and calcareous deterioration.
   Yacuolae are often seen under the microscope, doubt-
 less from atrophy of tissue, as would be the case  were
 the threads  of  a piece of woven cloth shrunken.
   There is  atrophy in the medullary nerve fibres.
 Lymphoid, spider and connective tissue cells are seen
 in large numbers both in  the grey and  white matter,
 but   irregularly  placed  in  the  different brains  of
 the paretics.
   It will thus be seen that it is essentially a death of
 tissue and  may  vary  very  much like the   slow
 natural process of  senile  decay, precipitated  by  the
 exhaustion of trophic energy or over stimulation, T)r
 the loss  of  nerve-cell  power of restoration, or from
tissue hypertrophy or abnormal blood supply from
want of tone in the vaso-motor centres.
  These radical changes are sufficient to  account for
the mental state and for the hopelessness of medica-
tion to affect a cure.  Much, however, can be  done to
ameliorate  the condition of this class  during  the
progress of the disease. 
PUERPERAL INSANITY.             87
CHAPTER IX.
             P UERPERA L INS A NITY.
Puerperal  insanity is a very  common form, and on
an average one in every  450 child-bearing women is
afflicted with it.
  As a matter of fact, however, it cannot be classed
as a distinct form  of insanity in  its manifestations.
The difference lies  in the  cause  rather  than in the
symptoms.  The  exciting cause or occasion is usually
and primarily in the disturbance set up in the sympa-
thetic system, and the brain trouble is a sequence to
it.  It may  assume  the form of mania or  melancholia,
and sometimes,  though  rarely, of  dementia.   One
form may follow  another in succession; that is, a case
may show  all  in its  progress towards  recovery or
chronicity.  We are  to guard against confounding puer-
peral mania with puerperal fever and its delirium.
They are distinct diseases, and the delirium  of fever
is not the mania of insanity.  The  muttering inanities
of fever have few features in common with the con-
sciousness and partial intellectual  endowment seen in
the lesion of mania.
  Puerperal insanity manifests itself at one of three
periods in a pregnant woman's life, viz :— 
S8               MENTAL DISEASES.
  1st. The insanity at any time during the child-bear-
ing period.
  2nd. The insanity taking place at child-birth.
  3rd. The post-parturient period, consisting  of  the
time of lactation and weaning.
  It is sometimes the  case, that in the  first-class the
insanity may pass away at child-birth.  The  gravid
uterus seeming to be the exciting  cause.  Such are
usually melancholia and delusional.   Some physicians
have recommended in  such cases the induction of pre-
mature labor, principally for two reasons : (a)  To put
an end to or at least shorten  the attack ; (6) To pos-
sibly prevent the production  of idiocy in the child if
it  should live, or to  destroy  it for the same rea-
son.  Apart from the  ethical feature of such  a prac-
tice, I may say that there is no reason to believe that
the mother would be benefited in any way by such
a radical  measure, as  many miscarriages brought on
by maniacal excitement have shown  no improvement
because of these mishaps.
  In the period of labour, especially in the latter stage
of severe and protracted parturition,  there is often
seen temporary delirium, and even a short period when
delusions may exist,  but which immediately  pass
away on the birth of the child.   This is not insanity,
properly speaking, as  it  is evanescent, and  not fixed
in duration.  Hereditary predisposition is an import-
ant  factor in its production.   Physical  causes are
more frequently  present  than are  moral  causes  or
emotional excitation.    At the same  time  anxiety, 
PUERPERAL INSANITY.             89
worry,  grief,  fear  and  such like  are often potent
factors as excitants.
  The insanity of lactation is usually  brought on by
the weakness  engendered from nursing  the child,
added to the only partially-recovered  condition from
child-bearing and labour stress.   In primiparous cases
the danger is great, especially J ate in life.
  Six weeks after confinement is the arbitrary limit
giyen to this form; but, of course, it may occur several
weeks after this time.  I would say that three months
would  be  nearer the mark, as so much depends on
constitutional, local or predisposing causes, and dis-
turbances beyond our knowledge, which  may take  a
long  period of incubation, or may not until the later
period have produced conditions favourable to its ap-
pearance.
   A  great majority of those cases  of the second-class
become insane within two weeks  after confinement,
 and the greater part of these within ten days.
   It  may be said there are two  classes of  those thus
afflicted, that is to say :
   1st.  When  the cause is apparently  and  simply
sympathetic.   In this class the uterus and appendages
 seem to be normal.   The cause seems  to be the shock
 to  the nerve centres, which are in an unstable con-
 dition and ripe for an outbreak.
   2nd. The septic.  In this class is not only weakness
 from loss of blood, physical exhaustion, mental excite-
 ment,  but also  septic  material from  even normal
 decomposition finds  its way into the open blood- 
90               MENTAL  DISEASES.
vessels  of  the uterus,  thence into the sanguineous
system, poisoning the brain in its flow.
   3rd. Some authors have a  class which  they name
phrenic.  They state that inflammation of the brain
supervenes on the invasion of a child-bed mania.  In
short, it is encephalitis, with sub-acute inflammation
of  the  meninges.    In  such an  attack we find not
mania, but simply delirium.  I have never seen such
a case, although it is possible such may  exist  through
the septic invasion into the skull cavity.  If  in puer-
peral patients  we  find  great  restlessness, insomnia
and  violence, with white-furred tongue, rigors, tym-
panitis, swollen legs, suppression  of  discharges or
foetid discharges, sallowness of  complexion, excessive,
clammy  sweating,  and feeble and  rapid  pulse, with
temperature very changeable,  ranging  from 100° to
104°, then has puerperal mania assumed a dangerous
type.
  In addition  to what has already been written, the
following points should be remembered :—
  1st. In a great many women there is a direct trans-
mission of a tendency to break-down  at  the  repro-
ductive times, just as we see at the trial epochs of life
in women and men.
  2nd.  Bodily conditions are to  a  greater  extent
exciting causes than  is moral or emotional distress.
  3rd. Child-bearing is more dangerous if not within
ordinary physiological limits ;  for example, first preg-
nancies  after, say, thirty years of age  and upwards.
  4th. Women who have had children,  but, after 
PUERPERAL INSANITY.
91
many years of a non-bearing period, have a child at
the menopause, are susceptible to be attacked.
  5th. During pregnancy there is a peculiar immunity
from  any severe sickness.   This is  not absolute, but
the absence  of  various  troubles  at  this  time has
attracted my attention.
  6th. A woman who has one attack is specially liable
to other attacks, if the pregnancy follows quickly on a
previous invasion.   It is possible that the dread of
another attack has an untoward psychical effect.
  7th. Some women suffer more when pregnant with
boys than with girls, and it may happen that insanity
accompanies the one or  the  other, but not often both.
  8th. Puerperal insanity  is more  prevalent among
the rich or  wellTto-do  than among the  poor.   The
artificial  living, the  less  vigorous  organism, the
neurotic diathesis so prevalent  in the  higher stratum
of society, the flabby organization for want of proper
exercise, the overfeeding, late hours and the unnatural
life of fashionable  society and such like, all tend to
physically and mentally unfit such  to face the  trials
of maternity.  The introduction of healthy mothers
from the humbler classes saves  the race  from extinc-
tion, as the well-known laws of  heredity show.
  9th.  Illegitimate pregnancies  seem  to be  more
dangerous  to mental integrity than child-birth among
the married.  Grief,  compunction  of  conscience, re-
proaches  of   relatives  and  social  ostracism   must
seriously affect the  bodily and mental  health of  such,
especially seeing many  are  young and not hardened 
92               MENTAL  DISEASES.

in vice.   The majority of these are not prostitutes :
therefore, susceptible to the loss of the social status.
  10th.  Among the poor the birth of twins is a serious
cause of mental  depression;  hence its influence  on
the mother to her hurt.
  11th.  Sudden frights, emotional  excitation,  blows
received, which may cause the  child-bearing mother
to apprehend, as a result,  deformity or injury to the
unborn child.  This may prey on the mind constantly
and  become a predisposing cause.
  12th.  It  is my opinion that the injudicious and too
frequent use of anaesthetics,  and the  use of instru-
ments  in many cases, which some mothers have a
terror of, may excite the malign  influence in heredi-
tary tendency.
  13th.  A  dislike of  friends  and  relatives  and  a
tendency to kill her offspring are often present.  In
such, there is usually an  element of  melancholy, ac-
companied  by emotional disturbance.
  14th.  My former teacher, Sir James Y. Simpson, of
Edinburgh, used to say that albuminuria was common
in such cases.  Dr. Campbell  Clark, of London, asserts
the same thing.   These statements are no doubt true •
and, as  renal  complications  are so often found in
insanity, they commonly cause  that form of disorder
at such  a time.
   15th.  Secondary troubles  often  set up,  such as
pneumonia, abscesses  and such  like.  The medical
attendant must  be on the watch  for these, as such a
development will complicate  matters very much. 
PUERPERAL INSANITY.
93
  16th. The  forms  which  puerperal  insanity  may
assume are almost as manifold  as are all the other
varieties of insanity.
  17th. The free use of instruments in labour may do
untold injury tp the child.  The  pressure upon the
brain  by them is very  great  through  a  powerful
leverage, and no doubt  produces molecular change in
a susceptible  organ, which may doom the unborn child
to idiocy or imbecility.  The necessary use of instru-
ments always gave me  chills from fear of untoward
consequences, not  only  to  the infant, but also to the
mother.  The  mental  anxiety  of  the mother when
their use is  proposed, and when they are applied, in
addition to the usual  distress,  may  be sufficient to
precipitate a  mania where inherited instability exists. 
94              MENTAL DISEASES.
CHAPTER  X.
              CIRCULAR INSANITY.
The most remarkable series of mental and physical
phenomena are those which constitute what is called
Circular Insanity.   (French, Folie Circulaire.)
  As far  as  we  know, the  pathological  condition
remains the same from year to year; yet, in spite of
this uniformity, we find  alternations  of  melancholia
antl mania, with intermissions, remissions or apparent
recovery between.
  This round  of  varied manifestations  is invariable
in sequence and variable in kind.
  In this morbid cycle the order usually is :
  1st. Mania, then  remission ; then melancholia, fol-
lowed by remission, and  back again to mania.   This
order of sequence is always carried out in the insane
life of each individual.
  2nd.  The initiatory attack may come in the form
of  melancholia, then remission, followed by mania.
This relation will then continue.
  3rd. Another class may have these two forms of
insanity in the  same order, but in the intervals, as
far as language and conduct are concerned, the patient
appears quite sane  for weeks at  a time, and were it
•                 •* 
CIRCULAR INSANITY.              95  •
not that we know the form of the insanity, might be
discharged as recovered.
  A few years ago, a political  superintendent of a
hospital for the insane, whose experience  was some-
what limited,  but  whose boastfulness  was ample,
entered in his annual statistics all  such  intermittent
cases as " cured."  He prided  himself on his superior
methods of treatment by  his recoveries.   His profes-
sional brethren, whom he was maligning by implica-
tion, showed the fallacy of  such  a record.  Eight
persons had in  twelve months been discharged thirty-
two times as " cured,"  making thirty-two  recoveries,
not of persons,  but of cases, as the  persons were only
eight.
   When the two stages  are  definitely  bounded the
period of  mental relief must of  necessity be equally
well marked.   In many the change takes place from
one form to another in a day, and in some  in a few
hours.  As a rule, the shorter the duration of each
form, the more intense is each.  One of the distinc-
tions in our-diagnosis of  these phases, from ordinary
mania and melancholia, is in these sudden  transitions
from one to the other, which is not a usual feature in
the distinct and separate forms.  They usually change
gradually, and  remain unchanged for a considerable
length of  time.
   It seems to  me  that the  exciting cause  of these
remarkable and regular changes  must  be in the
coming and going, in waves as it were,  of the vital-
izing energy, which is seen at ebb and flow tide, in all 
96
MENTAL DISEASES.
physical structures in health and  disease.   In  the
maniacal period of the cycle we have an over-activity,
which carries with it into the mental and physical
worlds  low inhibitory power and great exhaustion.
  From such depletion of the powers of life we have
the quietude of prostration,  to be  followed  by mel-
ancholia, from enervation.   Should  the  primary at-
tack be melancholy,  then  have we a step  towards
mania  in  the recuperation and rest  among easily-
disturbed  elements, which  gather  up  an energizing
power, which is  misdirected and  over-active.   The
balance wheel to the engine is out of gear, hence the
irregular movements.  In other words, the pendulum
swings from one extreme to the other by oscillations,
according to a general law of motion, seen everywhere
in operation in  nature.   Take another example:
An electric battery may,  by  undue  or  continuous
conduction, exhaust the fluid in store ; or, on the other
hand, the chemical energy by being  generated  too
rapidly soon becomes inert, as  its  manifested power
is  lost.   Allow  rest, and  this subtle  agent  will
reaccumulate, the necessary conditions being present
to generate it.
  The application is evident  by analogy in this form
of insanity.
  Circular insanity might be  illustrated as follows ; 
MELANCHOLIA
MELANCHOLIA       T>
          -fc.    NOISSIIAI^OXNI






                 >
                 z
VI-IOHONV-13IAI
CO
^1
* 
98
MENTAL DISEASES.
     These are among the cases which friends tease us
   to discharge.  The patients seem so well to relatives,
   either  in the  remissions  or  intermissions  that  no
   reasoning to delay avails much.  The heart of a near
   friend gets the better of the head, and a clinic to such
   against  haste is often a " Wasting of our sweetness on
   the desert air."  Many such  are brought  back in a
   few weeks or months with profuse apologies because
   of the precipitancy.   The friends  are not aware that
   the lowest point reached on the mental thermometer
   must  be permanently raised  to the normal before
   recovery can be said to have taken place.
     The conditions in this form vary much in duration.
   As  a rule,  in  each  cyclical invasion the melancholy
   exists longer than the mania.   The intervals of cessa-
   tion may be very short, in some  cases only  lasting for
   a few days at a time.   In others there are apparently
   no  intervals,  as the  one  condition is immediately
   followed by the other.  There is no doubt the inter-
   val exists before such a diverse change could possibly
   take place, but it is  not perceptible, so  evanescent is
   it.  The sudden plunging from the quietude and pros-
   tration of melancholia into the excitement of mania is
   often striking.  Sometimes the two conditions have a
   short  period between them  of  apparent  dementia,
\   or, more properly speaking, lethargy, yet this stupid-
!   ity is  more  apparent than real, for such  will  after-
   wards astonish you by telling what they remembered
\   while in this condition.
     We must  be guarded against  drawing conclusions 
CIRCULAR INSANITY.
99
too rapidly from seeing one or two alternations in this
form  of periodical  insanity, as these  may  exist for
one or two changes, and yet not be a typical case of
the double form.
  These may be only  ephemeral coincidents, such aa
are seen in puerperal mania followed by melancholia.
  Sometimes in periodic ovarian irritation we may
have  alternations, not  from inherent,  but outside in-
fluences ;  that is, from eccentric, not centric causes.
  A large number of this class belong to those  with
hereditary tendencies,  hence so seldom any  of  such
recover, as the  disease assumes  a fixity of  morbid
condition  when a few  cycles have made their malign
impressions on the  organism.
   It usually comes  on early in life at the pubescent
and adolescent ages.  There are exceptions, but they
are few.   At the  " trial epoch" of life the insane
diathesis,  in this alternating form, makes itself mani-
fest in this  persistent and  enduring form.  When
great physical changes are taking place the heredi-
tary neurotic weakness begins to make itself manifest.
   The two forms may vary in intensity.   The one
may be mild and the other severe; both  may be very
pronounced, or both may be mild.  There  is no uni-
formity in these respects, even  in the same individual.
   I came  across, the other day, in some publication a
statement made by Dr. Thomas Willis, a celebrated
physician, who  lived from A.D.  1622  until  1670,
which describes  in quaint language this periodic form
of  insanity, accompanied with alternations.  He  says : 
100             MENTAL  DISEASES.
" After  melancholia  we  have  to  treat of  mania,
which has  so  many relations  to the former that the
two  disorders often follow each  other, the  former
changing into the latter and inversely.  The melan-
choly diathesis, indeed, carried to its highest degree
causes frenzy, and  frenzy  subsiding,  changes  fre-
quently  into  melancholia  or  atrabiliar  diathesis.
These  two disorders,  like fire and  smoke, often
mask and  replace one  another, and if  we  may say
that in  melancholia the brain and the animal spirits
are  obscured  by  smoke and  black darkness, mania
may be  compared to a great fire destined to  disperse
and  to illuminate it,"
  That is a free translation of the Latin of this great
physician living nearly three  centuries ago.   It is a
good description  of  alternating insanity, and shows
keen observation  by this quaint old doctor.
  The pathology of circular insanity is what might
be expected from its etiology.
  There will be found atrophy of the convolutions to
some extent.  The membranes are thickened,  as is
also the  calvarium, and very often the arterioles are
found  to be aneurismal.  Large quantities  of  fluid,
more or less opaque, are found in  the ventricles and
in the subarachnoid spaces.  The whole condition is
that usually found  in the chronic  insane, and shows
the hopelessness of medication.
  The sanguine French alienists, however, think they
can  modify or prevent attacks by the free use of
quinine, or hasehish, or the bromides, or digitalis, or 
CIRCULAR INSANITY.
101
morphia,  and  such like.  When many  drugs  are
recommended to cure a disease, it is evident there is
no panacea for  it.

                Hysterial Mania.

  Hysteria, in its myriad forms,  is not insanity.  It
has no fixity as to duration.  There is no evidence of
pathological change anywhere, nor is there reason to
believe that such exists unless nerve instability merely
can be looked upon as such.   The temporary aberra-
tions are so evanescent  and the consciousness of the
existence of such a state do not point to mental dis-
ease of such a nature as to constitute it insanity any
more than we  see in the mere hypochondriac, who is
ever at his dying hour, or the neurasthenic, who has
delusions which come to him with painful persistency,
but which he sees  in their absurdity, and which he
reasons away for the time.
  At the same  time, this unstable condition  is on the
border-land, and is so deceptive in its appearance that
we  are to be guarded in diagnosing such a  case, lest
we confounded  it with epilepsy on the  one hand  and
insanity on the other.
  In hysteria we have a mind looking out for sym-
pathy.  The mental symptoms principally consist of
emotional disturbance, followed by weak will  power.
  There may be temporarily illusions, hallucinations
and delusions.   The mental activity may appear in
any form.  The shedding of tears, depression of spirits,
alternating with unusual laughter without  cause or 
102              MENTAL  DISEASES.
tears, and  for  a time  apparent lethargy, are well-
know  symptoms.    Sometimes  such  persons  are
emotionless and  simulate  melancholy.  The senses
convey in  their imaginations all kind of  erroneous
impressions.  It would take a  volume to catalogue
all their aches and pains, real or unreal.  The organs
of the special senses are sensibly exalted in a large
number, and  sometimes accompanied with pain.  It
is said that tenderness  over  the region of the ovaries
is a pathognomic  sign, but  the mind  may  conjure
up pain when it does  not exist, as we know it does
in  so-called  " spine disease"   or  joint disease,  or
hysterical  paralysis; the sudden departure of which
has  been  a  rich  field to  cultivate by  Fetichism,
Voodooism, " Faith-cure" and  such like.   The  emo-
tional  or  the  devotional intensity puts an end to
the hysteria  in those  forms.  The  clonic and  tonic
spasm, the hysterical aphonia, the tonic spasm of the
pharynx (globus hystericus), spasm of the stomach,
intestines,  bladder and limbs  are  physical  signs in
which there can be little deception.
  H}steria bears,  in many  of  its aspects,  a  striking
simulation to  some forms of mania, but any shrewd
practitioner, with his wits about him,  needs never be
deceived.
  It is a noticeable fact that simple hysteria  exists to
a limited extent among the  insane,  although  it  is of
nervous origin.  At the same  time, it often has an
existence because of hereditary tendencies to insanity,
and may be  the first  degenerative step towards pro- 
CIRCULAR INSANITY.
103
nounced and subsequent insanity.  When we have a
case of hysteria, epilepsy and insanity in conjunction,
then  have we  a trio which  indicate  permanency.
Hystero-epileptic insanity is usually very intractable
and difficult to manage.

               Concealed Insanity.

   Many persons know by their feelings that insanity
is coming upon  them.  The  mental  depreciation  is
recognized, and they  heroically fight against its in-
vasion as far as their conduct is concerned.   With
strong will the  errant, mental  stream is stemmed for
a time ; but, as a rule, the flood  comes with greater
impetuosity  because  of  a temporary check  to its
headway.  This effort is  made by many before they
are sent to an  asylum, and if the brain lesion  is not
extensive the mere force  of will keeps language and
conduct within reasonable bounds, although, in the end,
the barrier is thrown down.
   In circular  insanity it  is distressing  to see the
patients struggling  against the inevitable, which re-
peated experience tells them  cannot be checked.  In
the interval of mental quietness and rationality they
are cognizant of  the coming invasion of  one form or
another of melancholia or mania, and dread the assault.
These forebodings often precipitate the outbreak, for
"coming events cast  their shadows before."   Those
who have delusions  and are otherwise sane, may and
do successfully conceal such  for  a time, until some
emotional shock or   general  personal  disturbance 
104
mental diseases.
brings to the surface  the  latent but potent factor in
the well-covered alienation.
  When a physician is called to certify to the insanity
of such a person  it needs all  his adroitness and tact
to bring the patient to unmask himself.   In fact, the
patient  often  puts the questioner  on the defensive,
especially the delusional  paranoiac or the  cunning
melancholic.   These  classes  often show  so  much
shrewdness, and at the same time so  much suspicion,
that the questioner is supposed to be hostile to such,
or is forwarding  his own plans or  interests thereby,
so it may require  many visits in order to procure
undoubted evidence of insanity based upon observa-
tion.   If friends injudiciously attempt  to remove
delusions by repeated arguments with the patient, he
soons learns that it is best for him  not to touch upon
them, hence his reticence about the  morbid ideas upon
which an opinion must be based.   It is patients of
this class which make the public believe  they  are
sane and wrongfully detained in an  asylum, and eager
newsmongers  fill the  newspapers with the  presumed
outrage.  On  the other hand,  we sometimes find even
the insane simulating insanity.  The dement, nor the
melancholy, nor the  maniacal will pretend this, be-
cause of the mental incapacity of  the first, the pro-
found feeling of misery in the second, and the intense
self-exaltation of the  last; so these do  not act the
deceivers.  The cunning  delusional lunatic is usually
the one, or he with  " antic disposition."   His  object
usually is to excite extra sympathy, to have a good 
CIRCULAR  INSANITY.
105
excuse to avoid some  kinds of  distasteful work, or a
mere freak to imitate  others whom he sees about him,
or to obtain  some toothsome medical comfort  as an
insane invalid; thus tracing cause and effect.  It is
not hard to detect such cunning in the actor, and it is
amusing to see such drop  the mask when they have
failed in their purpose and resume unknowingly their
insane state; yet these  peculiarities they cannot ob-
serve in themselves.  They can act insane as copyists,
but  deny  "the soft  impeachment" when charged
against themselves.
   I have often  heard insane medical men diagnose
correctly  the  various classes  of the insane around
them, yet fail to discern their own morbid condition.
This wrant of self-knowledge is not, however, confined
to the insane. 
106              MENTAL DISEASES.
CHAPTER  XI.
                  MELANCHOLIA.
The radical symptom of insane  melancholia  is  in-
dicated  by the  expression of  a  feeling of misery in
which no sufficient justification exists  in the circum-
stances of the individual.
  Associated with this cardinal symptom are usually:
  1st. Defect of  nutrition and  of other  bodily pro-
cesses.
  2nd. Defect or  abnormality  of conduct.
  3rd.  Commonly the existence  of delusions.
  The  feeling  of misery is  expressed  by (a) the
face, (6) by attitude,  (c) by  gesture,  (d) by verbal
expression.
  The  lines of* the face are changed into a woe-be-
gone expression.
  The  attitude is one of general flexion.  An  erect
figure is seldom  seen  in  this malady.  The head is
usually  bowed  ;  the  back is bent;  and, in severe
cases, the legs are flexed at the knees.   The tendency
of the thumb is to lie, not opposed to the fingers, but
parallel with and alongside of them.
  Among the gestures expressing misery, the  most
prominent and  characteristic  is  that of wringing the 
MELANCHOLIA.
107
hands.  Sometimes the eyes are dry, but often full of
tears.  Very loud, obtrusive weeping  does not appear
to be associated with deep melancholia.   Wringing of
the hands may be either constant, frequent or  occa-
sional.  Sighing and groaning, striking the head with
the  fists, sitting with  the  face buried  in the hands,
standing for a considerable time  in one attitude, sit-
ting and  rocking the body backwards  and forwards
are usual.   The pulling of the hair is not by handfuls,
but possibly a  hair at  a time, not in a maniacal way,
but  rather from a spirit of unrest.
   The verbal  expressions  are not numerous, and, as
might be  expected, are of  an emotional  character.
The utterance  of misery is not always proportionate
to, nor a  measure  of, the  degree of  mental  pain
which is felt.   It may exceed it because of automatic
repetition, and thus the expression is in excess of the
feeling, or the expression  may be suppressed  while
the  face  and gestures may tell a story  of mental
distress.
   In this  day  we are largely trained to  suppress
our  emotions, and this inhibitory power often extends
to insane conditions.
   The bodily functions are unsatisfactory,  as a rule,
in true melancholy.
   1st. Defect of nutrition throughout the whole body,
as is evident in  non-assimilation or  mal-assimilation
of food.
   2nd. The skin is dry and  is often of an unwhole-
some tint. 
108
MENTAL DISEASES.
  3rd.  The hair is dry, harsh, and often lacks natural
smoothness.
  4th.  The mouth is dry;  the tongue  is furred ; the
bowels are constipated; the urine is loaded;  the pulse
is slow; the  body temperature is  lowered ; in short,
the sum total  of  the bodily processes  are below par
or wanting in vigour.
  This description is intended for  a typical and pro-
found case of  insane melancholia.  When the  feeling
of misery is not very great, these  pronounced symp-
toms may be very much modified.
  Many have  delusions of a positive nature;  but wre
have many cases, especially in the  initiatory stages,
in which  nothing is  prominent but a sense of ill-
being, in which is abject misery.   Melancholy comes
on in its invasion as such, and does  not spring out of
any other form  of insanity, as a rule.  Other forms
may be planted on it, such as mania and  dementia;
but not it on them.
  Usually the onset of  melancholia is gradual.  In
this it differs  from many other  forms.   The dulness,
the inertia, the uneasiness and  the lessened interest
in life  may not be noticed by friends at first.
  In a retrospect of  a pronounced  case, these changed
conditions are remembered as  the first departures
from the  normal standard, and  also how insidiously
they come on.
  A large proportion of  young patients  recover, and
often rapidly and completely.  In  elderly people  I
have seen the disease progress rapidly towards  re- 
MELANCHOLIA.
109
covery and then come to  a  stand-still, and so remain
on  the  margin  of mental  recovery,  yet such may
never reach the former land-mark of health.
  Melancholia is  very  liable to relapse, and  it may
take place at any period of life.  On the other hand,
this disease  may terminate rapidly in death.  The
patient is a poor eater  and  sleeper.    He  becomes
thinner, weaker, more dejected, with little energy, and
finally dies of exhaustion.
  Death  may occur  in  a few weeks  after  positive
invasion,  or life  may terminate after months of ill-
ness.
  If  recovery or death do not ensue  in, say, about
a year, then is it usual for this disease to change its
form into some other phase of insanity, or other forms
alternate with it in  circular insanity.   It then takes
its  place in the continuous round of  remittent but
fixed alternations of different phases of insanity.
  The  varieties of melancholia are many, no fewer
than thirty kinds have been classified by authors.
  For all practical purposes it may be  said that we
have, viz. :
   1st.  Simple melancholia.   This form consists only
of  sufficient mental depression to affect the usual con-
duct of the patient.
   2nd. Melancholia, with delusions.
   3rd.  Stuporous melancholia,.  This form is accom-
panied with  mental listlessness, bordering  on  de-
 mentia.
   All  these forms are  active or passive, depending 
110
MENTAL DISEASES.
upon  outward manifestations or the want of them.
This,  however, is  an artificial  classification, as the
same patient may alternately  be in all  these condi-
tions.
  Some make a class to which they give the name of
"suicidal  melancholia."    This only means that the
impulse takes  the form  of suicide.  Many  of the
homicidal belong to this class also, as the  delusions
are, so may be  the mental bent;  and many names
would be needed if a particular bias  requires a dis-
tinct term.
  Many of the  less melancholy  are the most deter-
mined on  self-destruction.
  It is a curious fact, which I have noticed, that if a
particular method  of suicide  is determined upon no
other plan is usually concerted, hence  the  advantage
to us  in  supervising such, to  study  the  form the
impulse takes.
  When once a person has determined  to kill himself
it is well nigh impossible  to prevent him from carry-
ing out his intention, if this state continues for some
length of  time.
  A  book might  be written on  the cunning and
strategy manifested by such.  The capacity to keep
the mode  secret and the tenacity of purpose, regard-
less of personal comfort or pain, are objects of wonder
to the sane.
  The tendency to commit suicide having once exhib-
ited  itself in any case, it renders that  patient forever
after a source of anxiety to those who have the care 
MELANCHOLIA.
Ill
of him.   In consequence of the  want of proportion
between the tendency to suicide  and the manifesta-
tions  of  melancholy it becomes  impossible  to infer,
with  any safety, how  strong  the impulse may be.
Many cases are on  record in which  such  patients,
who have apparently recovered from  this condition,
have committed suicide  on  being freed  from restraint.
The ingenuity with which such a patient will construct
deadly weapons out of the most harmless instruments,
such  as the material of clothing; the secrecy with
which he will  carry out his preparations, and the sud-
denness and determination with which he will carry
them into  effect are such  as, if  persisted in over a
long  period, to  render  futile  the most stringent
watchfulness and precaution, especially if under home
supervision.
  The sharpening  of  bits of  barrel hoops,  of nails
and pieces of wire, of  bone and of small pieces of
glass—gathered, it may be, in the  grounds while walk-
ing—are matters  of  almost daily occurrence when
suicide, by the use of them, is intended.
  Female  patients will pull  threads out of  their
sheets or clothing  until they have enough to  twist
into a cord wherewith  to strangle themselves.   They
will even utilize hairpins, or combs, or crochet-needles
for the same  purpose.   One man will  hang  himself
from a bedstead post three feet high;  another will
drown himself in a basin of water; a  third will stuff
a lump of  meat  into his throat and suffocate  himself.
  I have known one case of a woman, who committed 
112
MENTAL DISEASES.
suicide by chocking herself to death by pulling a slip
noose on a handkerchief tight around her throat with
her hands, while she sat on the floor of her bedroom.
  The notion  of suicide  varies with the  education
and surroundings of the individual.  Suicide is more
common  in  some forms  of  insanity than in  others.
There is,  however,  hardly a  distinct group of cases
deserving the term of  suicidal mania.
  Suicide may be accidental or intentional.
  In  acute mania and paresis, if suicide occur,  it is
generally as the  result of  accident.
  " In some cases of emotional disorder there may be
an intention to pretend to commit suicide, which may,
by accident, become effective.
  " In maniacal states suicide is  rarely the result of
deliberate purpose.  It may result from impulse; or, in
mania of the frenzied  delirious type, it may follow or
depend upon hallucinations of the senses, which may
lead to dread of something or someone; or it may be
obeying some Divine command given by voices, or by
some  inward monitor prompting  to the deed.  The
patient who thinks  he can fly may jump from a three-
storey window, or he who thinks he can walk upon the
water may try and  drown.
  " In some neurotic persons, whether the neurosis
result  from  heredity, alcoholism,  previous  attacks,
injury to the head,  or in connection with some other
bodily ailment,  slight  moral  causes  may lead  to
suicide.  Such cases may be called neurotic suicides,
and in  these we  frequently meet with  a history  of 
MELANCHOLIA.
113
suicide  in  other members of the  family.   A slight
strain  of  mind  leads  to   melancholy  and   self-
destruction.  It may  even occur  in  the automatic
stage of epilepsy or as the result of uncontrollable
impulse."—Mercier.
  The suicides of the insane form are usually divided
into two classes, viz.:
  I. The impulsive kind.  These are subdivided into :
(a)   Neurotic;  (b)  Hysterical;  (c) Maniacal;   (d)
Alcoholic ; (e) Epileptic.
  II. Deliberate suicide jnay depend on :
  1st. Egotistical feelings, such as pain, worry, sleep-
lessness, ruin, shame, to avoid persecution, etc.
  2nd. Altruistic feelings, such as to save others from
suffering or to benefit  others.
  3rd. Indifference to these existing causes, but as the
result of "voices," of fixed delusions, or of weak mind.
  In diagnosis the  nearest ally to melancholia, and
the  maladies for which it is  most likely to be  mis-
taken, are  dementia, hypochondriasis and hysteria.
  To dementia  it is allied not merely  in appearance,
but in  nature, for the  melancholy  feeling never
reaches a morbid degree without some general weaken-
ing of the mental powers, which  constitutes a slight
degree  of  dementia: and, in  well-marked cases, it is
melancholia  plus  a  veritable dementia.  They blend
together, as,  in  fact, do all the forms  of insanity in
some one or other of their stages.
  Melancholia differs  chiefly from dementia  in the
superaddition to the symptoms of the  latter of evi-
     8 
114
MENTAL DISEASES.
dence of  depression of  mind.   This evidence over-
shadows all other conditions, and is paramount in the
patient's  mind.  The sadness stands  in the front of
the mental photograph and is most conspicuous, and
jhis is the differentiating symptom in the diagnosis.
  Hypochondriasis is distinguished from melancholia,
to which it is very nearly allied, by the persistence with
which the patient assigns h is fancies to bodily disease,and
by the degree in which his thoughts are enthralled and
engrossed by  his bodily condition.   Between hypo-
chondriasis and melancholia^ there is every  possible
gradation.
  The hypochondriac  is  distinguished  by  his en-
thusiastic acceptance of remedy after  remedy, and his
eager pursuit after all nostrums  which promise relief.
He is the bane of  the medical  practitioner, and his
whims are endless.  Throughout  all the dread  and
wretchedness of his career  he clings fast to the  faith
that he will  at length  discover the man  who  shall
administer the drug that will cure him.
  The melancholy man has no such hope.   No ray of
comfort brightens the gloom of his life.  So far  from
entertaining hopes of recovery or confidence in treat-
ment, he  rejects  with  something like contempt, the
advice that is tendered  for his welfare.
  There is not much danger in mistaking hysteria for
melancholy.
  In  hysteria the whole aim and  end of display of
symptoms  by  the  patient will be  found to  have 
MELANCHOLIA.
115
   regard to the  attraction of notice, of interest, and of
   sympathy from others.
     On the other hand, in melancholia the patient is
   quite indifferent to the  way  in  which  his  actions
   and  symptoms  may  impress  other  people.   Such
   are  too  much absorbed  in the  misery  that they
   suffer to  bestow a single thought upon  the  way in
x  which their conduct is regarded.   At the same time
   it is not to be forgotten that misery, such as theirs, may
   have a reasonable cause, and is not  a diseased con-
   dition at all.
     If  a patient appears afflicted with melancholy, and
   declares that he is on the brink of ruin of character,
   that his wife  has deserted him  or is  unfaithful  to
   him, that he is a wicked and dishonest man, that he
   is liable  to arrest, that financial  ruin is  staring him
   in the face, it is  necessary to be cautious in regarding
   his statements as unfounded.  It may be they  are
   true, and that his feelings  of misery  are  only  the
   natural outcome which such circumstances ought to
   excite in a normal mind.
     We have to do  with the non-existent fancies as
   primary  causes  or secondary results.   All  these
   troubles   may  induce  pathological  conditions,  but
   caution is needed not to confound  natural  sorrow
   with unnatural grief;  sane depression of  spirits with
   insane  melancholia.   When  analyzed,  the  trans-
   gressions  of these insane melancholies are of  a very
   venial kind.
     To patients they are  of  vast importance, and,  in 
116
MENTAL DISEASES.
their estimation, on them  hang the issues of life and
death.   Such may have sinned grievously in putting
on a wrong dress when preparing to go to church, or
in wearing a necktie of  a particular color, or perhaps
in eating a particular kind of food.  The most childish
notions are looked upon  as being mortal sin; and,
because of  cherishing  them,  they are doomed  to
eternal torment.                                     /
  Molehills of  neglect are magnified into  mountains
of guilt.   To  many such melancholy persons these
trifles are, in the sum total, "the sin against the Holy
Ghost," and, according  to the Holy  Scriptures,  can
never be forgiven in this world nor in the world to
come.
  Such expect  no post-mortem salvation,  and as a
result  of these  sad forbodings they are so miserable
that they wish to die ; and, as a consequence, this psy-
chic pain makes them intensely suicidal.   Strange to
say, although such fear that their souls are to be for-
ever lost and that there is to be a terrible reckoning for
them in the future, they piteously  beg to be allowed
to plunge  into  this supposed  state of misery and to
receive this looked-for judgment  of  condemnation.
There  cry  is virtually, "Anyway to  get out  of  this
present world."   Anything, anywhere, to escape from
the horrible present and  to avoid the hideous spectre
of an ever-present sense of apparent guilt.
  To the  insane all  delusions are facts, and the most
cogent reasoning  cannot drive them away.  The mind
is constantly " racked with one idea."  The one sunny 
MELANCHOLIA.
117
glint  in the cloud is the fact, that, in  spite of the
tears, the wringing  of hands, the sad introspection,
the moaning, and  self-accusation, many  of them eat
and sleep fairly well, if in the chronic stage, and should
they remain insane, many live to  a good old age.
  Those  who recover  look back to those  days of
morbid and sad fancies as they would to some dismal
night-mare, which leaves nothing but a  sad  memory
in the morning.
  Outside of the possession of these ogres of imagin-
ation the intellect  is comparatively  unaffected, hence
is their condition  the  more deplorable as they know
well everything connected  with their  position  and
surroundings.   Their appeals to be put out of  this
mental  pain by premature death  are  pitiable,  and
would wring sympathy from  the most  obdurate and
callous nature.
  Those who believe they have committed the unpar-
donable  sin  are the  most wretched of  this class.
Women are more subject to this form of insanity than
are  the  men.   The press  very often  gives us sad
accounts of mothers  who are  naturally  possessed of
the  maternal  instinct, but who have  put to death
their children  and  then have  committed  suicide.
They usually belong to this  melancholic  class,  and
on  account  of their intelligence  outside of the  pro-
found sadness, are not considered dangerous to them-
selves or others until some terrible tragedy has taken
place.  They often reason to themselves thus :  " This
is a  wicked, heartless and miserable world, so  I  will 
118
MENTAL DISEASES.
send my children, whom I love, to blissful regions  in
the world beyond, and I will immediately follow them.
It is my duty so to do."  The  mothers see  no harm
in the  killing, as in such the  moral judgments are
perverted.
   Did the delusions of these sad unfortunates lead them
to believe  there  was no hereafter,  and that suicide
meant annihilation and consequent freedom in death
from these sufferings, the intense desire to kill them-
selves might have some consistency.  Such is not their
belief, however; but, on the contrary, they are believers
in an immortality, although  their moral  natures are
perverted and supersensitive to an  abnormal degree.
All the judgments and denunciations  they can find
in the Bible are, in their estimation  and  morbid  im-
agination, hurled at them, and are meant personally
for them.   They reason that the present is insufferable
and the future in the world to come can be no worse.
   It is a common  impression that the melancholy are
so taken up with  themselves  and their ever-present
sadness  as  to  obliterate the past.  Poets  are very
much to blame  for giving these impressions, purely
from ignorance of the facts.
   Penrose (an old poet) sang falsely in saying:
      " Forgotten quite, all former scenes of dear delight:
          Connubial love—parental joy—
        No sympathies like these his soul employ ;
          But all is dark within."
   As a matter of  fact,  it is  the past which troubles
them with its memory of sins. 
MELANCHOLIA.
119
  It is satisfactory to know  that, sooner  or later, a
goodly number  of  this class recover, especially if  no
taint of an insane tendency is present in the constitu-
tion.  Even then recovery is not hopeless, for nature
is ever struggling towards health.
  Were  it  not   for  this grand  principle or law  of
health, mental vigor would soon  be the exception to
the  rule, and no one could be found  to be mentally
competent to keep  the  keys  of  the  doors of  an
asylum.
  As I have said, the cunning of such to enable them
to bring about  self-destruction is wonderful, and the
utmost vigilance of nurses and  attendants is needed
to prevent it.  A book might be written on the ways
and means  they can and do adopt to accomplish their
 ends.
   Burton,  in his  " Anatomy of   Melancholy,"  has
 written a fascinating book on this subject, although
 this was done many years ago, as did also the English
 Chartist, Thomas Cooper, over half a century ago, in
 his  " Purgatory of Suicides."
   Shakespeare  has drawn, with  the brain and pen of
 poetic inspiration,  a faithful  portraiture of this class
 in such  a sublime creation as " Hamlet."
   Burton exaggerated a good deal, as those possessed
 with the versifying  frenzy are apt to do, yet, on  the
 whole, his dismal picture is  true when applied to  the
 delusionally insane.  See, for example, such stanzas as:
           '' Methinks I hear, methinks I see
              Ghosts, goblins, fiends ; my phantasy 
120
MENTAL DISEASES.
             Presents a thousand ugly shapes :
               Headless bears, black men and apes,
             Doleful outcries and fearful sights ;
               All my griefs to these are jolly,
               None so damned as melancholy.

             I'll change my state with any wretch
               Thou canst from gaol or dunghill fetch ;
             My pains past cure, another hell,
               I may not in this torment dwell.
             Now desperate, I hate my life,
               Send me a halter or a knife :
             All my griefs to these are jolly,
               Naught so damned as melancholy."

   The  misanthropic but gifted  Byron gave  a  mental
photograph of himself when he sang:

           " Melancholy is a fearful gift;
               What is it but the telescope of truth ?
             Which strips the distance of its phantasies,
               And brings life near in utter darkness,
               Making the cold reality too real."

   This  is  the agonizing  cry of a  sane soul, ever  in
unrest, like the troubled sea.
   Crabbe, the melancholy poet, could write  from sad
experience such words as these :

         " Oh, how the passions, insolent and strong,
             Bear our weak minds their rapid course along ;
           Make us the madness of their will obey,
             They die, and leave us to our griefs a prey."

   Shakespeare, the greatest of the students  of  nature,
penned truthfully of those who are afflicted as Ham-
let was said to be: 
MELANCHOLIA.
121
        " His brain is wrecked—
            For ever in the pauses of his speech
          His lips doth work with inward mutterings,
            And his fixed eye is riveted fearfully
            On something that no other eye can spy."
        1' Canst thou minister to a mind diseased ?
            Pluck from the memory a rooted sorrow,
          Raze out the written troubles of the brain,
            And with some sweet, oblivious antidote,
          Cleanse the foul  bosom of that perilous stuff
            Which weighs upon the heart."
  It may be said in passing that many  of those who
are afflicted with insane despondency are silent, and
give no expression  of  their grief  in words.   Their
manner and mute appeals tell the story of their woes.
Others are  very talkative, and, with  great volubility,
pour out their  plaint and plead for succour from im-
aginary troubles to anyone who will listen to their
miserere.
   Some, who are only  afflicted with the milder form
of  melancholy, seemf to  take a  sort of pleasure in
reciting their miseries, and this is done with tiresome
repetition from day  to  day, even were it to the same
person.
   It is a constant localization of the  mind upon itself
and its painful  workings, yet these do not produce in
the  chronic  melancholic  that  profound  physical  and
mental prostration which such  forbodings would do
were they possessed by the sane. 
122
MENTAL DISEASES.
CHAPTER  XII.
                MORAL INSANITY.
THE  INSANITY OF MORALITY OR AFFECTIVE INSANITY.
It has been  denied that there is a  disease of  the
moral  powers apart  from  simple and  responsible
wickedness.  This denial has largely arisen because
of abuses in  courts of  law, where a plea has been
made to shield  sane  culprits on the ground of  the
possession  of  such a form  of  insanity.   If  there
exist emotional insanity and intellectual  insanity, it
seems  somewhat illogical  to expurgate  a form of
mental  disease the  principal feature of  which  is
dethronement of  the  moral  feelings and of  the
capacity to formulate  moral judgments.
  There  is no doubt in  my own mind such a disease
exists altogether distinct from responsible depravity.
It is not a steady advance from one degree of wicked-
ness to another ;  but is a change, often suddenly, of a
man's moral  being, which makes  the man altogether
different  in character and conduct when compared
with his previous life history.  It may be a blow on
the head, a sunstroke, an attack  of fever, a  nervous
shock, or any such  physical injury or  disease which
is the precursor and cause of the great moral changes. 
MORAL INSANITY,
123
From the stage of convalescence the moral change in
the man is seen.  His views of his relations and duties
to his family, his  friends, his neighbours and to society
have undergone a transformation for the worse.  He
is unnaturally short-tempered and stubborn in errant
ways ; he becomes a great  liar; he is prompted by
dishonourable conduct, full of suspicions, profane and
abusive in language, and  addicted  to profligacy  of   •
various kinds.  In short, he is no longer  himself, and
his change astonishes all who come  in conduct with
him.  The dividing line of the two diverse characters
in one person  is  at the  termination  of the disease.
Here the moral malaise begins.  All these deviations,
so diametrically opposed to his former self and to his
own best interests, show intellectual as well as moral
lesion.  Both co-exist and are manifested together in
some degree.   He cannot see the inconsistencies  in
his conduct and life.  He cannot discern the sudden
and total  change in  himself,  but  readily  accuses
others of all kinds  of evil-doing.  He has sufficient
cunning to torture, tease and  annoy the  members  of
his family in all  imaginable ways, and yet at times,
especially before strangers, is the model of propriety.
  In  some cases the disease, which  has dulled  the
moral faculty,  has sharpened the intellectual;  and,
because  of  this  want  of  balance  and  one-sided
capacity, there are a sharpness and a shrewdness, com-
bined with maliciousness, which  renders the  lunatic
the very incarnation of  hate  and mischief.  At the
same time he may be able to cover under a plausible 
124
MENTAL DISEASES.
exterior, with great skill, his own defects, and paint,
with  considerable  eloquence,  the  real  or imaginary
shortcomings of others.   If such have delusions, they
may hide them for a time from the keenest investiga-
tion, yet extravagant  ideas may exist which no sane
man would harbour,  but which lie in covert behind
the well-constructed  curtain  of   a  man's  outward
conduct.
  Such cases are not far removed,  in brain and mind
action, from the congenital criminal, and the acquired
and vicious class of the sane.
  The fulcrum diagnostic symptom between this class
of affective insanity and natural depravity is the mode
of causation.  Is it  a natural development and purely
physiological, or a disease, and  therefore pathological ?
On  the answer hinges  the correct solution  of  each
case.   Were it a natural development, then  would  it
come on gradually, and the man's previous life history
would  show him  to  be  a  sinner revelling  in his
depravity.   If  it is a  disease, we can  trace its in-
vasion and progress  by the patient's language and
conduct. It is not the outcome of  a habit of vicious-
ness formed by repetition or congenital, but a change
of nature superinduced and controlled by brain disease.
  At  the same time,  if a man had, previous to the
attack of the causative  disease, naturally vicious or
criminal propensities,  or had acquired  them  from
habitual wrong-doing  or because of precept  or exam-
ple  until they had  become a  second  nature to him,
then is it evident that  such an ill-conditioned brain 
MORAL INSANITY.
12o
and mind are  more likely to drop  into the groove of
affective insanity than would  those more favourably
constituted.
  There is moral insanity without illusions, hallu-
cinations or delusions.  There is a perverted state of
the active and moral  power included under feeling,
volition, affections, propensities, temper,  habits and
conduct.
  At  the same time  we are  not  to  ignore, in  our
diagnosis, the  existence of  wilful vice, a wicked dis-
position, the influence of bad associates, evil example
and reckless depravity, either  congenital  or  acquired.
  In moral insanity reasoning must  be tainted, and
the intellectual faculties are more or less involved.
  The very reason why  a patient is so  eccentric and
perverse in conduct, so destitute  of natural  affection,
so changed in sentiment, is that  he no longer realizes
his duties and  his relations to his family and society.
His ideas in  regard  to himself  are  false and mis-
chievous, but,  as his natural feelings are restored, the
intellectual powers once more gain the ascendancy.
  When recovery takes place, the  comparison of  the
two distinct lives is  most striking, and shows from
what  a depth he has risen.  This change is evident
to the patient himself.  It  is well  in courts of law to
distinctly state that, in the insanity of morality, there
is always an  intellectual lesion, and that the moral
obliquity is an outcome of  this mental dethronement.
If not  thus distinguished, you  will  be asked  how
you can diagnose sane  anger, revenge, malice or  a 
126
MENTAL DISEASES.
 wicked  heart  from  insanity with these  manifesta-
 tions, and  you will fail to do so to the satisfaction of
 a judge and jury.
   In fact, you will be accused of attempting to shield
 a  bad man from just punishment, under  what they
 may and delight to  call " the groundless plea  of
 insanity."
   It is often difficult  to lay down  rules by which  to
 differentiate moral insanity from moral depravity.
   Each case must be decided in relation  to the  in-
 dividual himself: his antecedents,  education, sur-
 roundings, social  status,  the  nature  of certain acts,
 the mode in which they were  performed, the diseases
 and  injuries (if any), the estimate of conduct from
 definite periods, and  any other circumstances which
 would fairly raise the suspicion that these devious
 ways are not under his control.
   Do not mistake moral imbecility with the insanity
 of morality.
   The former  means want  of  mind development,
 while the latter means morbid perversion or a want of
 proper direction  and  balance in  the moral nature
 because of mental disease.
   The former class of persons may  have great acute-
ness  and mental  scope in certain  directions, such as
music, arithmetic or mechanics, yet may lie, steal, be
cruel beyond  conception,  and  be beastly in  their
instincts and destructive in their habits.
  In the latter  class  we have  the normal  man  in
feeling,  intellect  and morals  up to a certain  stage, 
MORAL INSANITY.
127
then moral  collapse.  A number of cases might  be
presented to illustrate this class of persons.  Three
must suffice, as they are typical of all.
  A man of about fifty years of age lived near where
I once practised.  His occupation was that of a farmer,
and he lived in one location nearly the whole of his life.
He was honest, quiet, industrious—a good man—his
word  was  as reliable as  his  bond, and he was of a
retiring disposition.  One  day, while he was working
in the hay field, he  had a  sunstroke, and was  semi-
unconscious for about half  an hour.   This was fol-
lowed by slight delirium for about twenty-four hours.
He then recovered his usual health, but in those few
hours of illness the man's moral  nature had entirely
changed.  He became peevish, erratic, profane, un-
truthful and thoroughly unreliable.  With low cun-
ning he would tease the members  of his  family, for
whom he formerly  had a  strong affection during a
long lifetime, in all conceivable ways.   No one would
believe he was the same man, yet the total change  of
character took place  in a  day.  This  could not  be
merely moral depravity of  a sane  person.  We trace
the perversion from brain injury caused by sunstroke.
He remained in that condition until death, two  years
afterwards.
   Another case was  that  of  a young  man twenty-
five years of age.   He was an exemplary son of aged
parents, and  well  spoken of by all the neighbours,
as  he  deserved  to be.  One day, in the  winter-
time, he was felling a tree in the woods for fire-wood, 
128             MENTAL DISEASES.
when a small dry branch became  detached  from the
tree near its top.  It came down  and struck him on
the head, knocking him  insensible.  He  lay in  this
condition for some time,  and was  found  by friends
where he fell.   For about a week he lay in  a stupor,
with intervals of  restlessness and  muttering incoher-
ency.  He finally recovered his reason as far as could
be detected,  but his character was  changed  in many
ways.  He would neglect his  work,  swear  viciously
when  reprimanded,  use  obscene  language  in  the
presence of his parents and of his neighbours.  At the
same  time he was shrewd, and beyond these incon-
sistencies showed no lesion of intellect.   We  have
here a dividing  line of conduct and  character at the
time of the accident.  No one would dream  of saying
that  badness  lay at  the  bottom  of  such  moral
obliquity. The organ of the mind was, for the time,
out  of order.  In about a  year  he  recovered,  and
" came to himself " once more.
  The third  case was  that  of a  young  woman, the
oldest of  a  respectable  mechanic's daughters.   She
was  a steady,  quiet,  well-behaved  and intelligent
member of the  family.   Having  an  invalid mother,
and  being the  eldest,  she was as a  mother to the
other children.   She was taken  with an  attack of
typhoid fever of a severe type, and was delirious for
nearly two  weeks.   On  her recovery she manifested
a change of character, altogether unnatural to  her.
She  was  talkative,  nervous,  irritable, erratic  and
untruthful  to a degree  which astonished  everyone 
I
                 MORAL INSANITY.              129

who knew her.   Some good  people thought  this was
caused by satanic influence,  others that it was inher-
ent total  depravity  cropping up; but  in about  six
months she returned to her former  self.   Diabolus
and sin seemed to  have permitted the  former excel-
lency to resume its  sway.  She married afterwards,
and  was  an exemplary  wife  and a fond  mother.
These  three  cases  might be multiplied indefinitely
from medical literature, to show that such causes and
such effects are very common.   Now, in many brains,
lesion may come on  from causes  not  so pronounced
or  even unknown  to  us,  but the  ethical results
would be the same and* based on diseased  conditions,
producing utter irresponsibility.
   Changes may take place in the molecular  structure
of the brain, and may come on gradually, which might
so change the direction and function of that organic
centre as to  produce this form of affective  insanity,
yet no initiatory stage could be pointed out. 
130              MENTAL DISEASES.
CHAPTER XIII.
           EPILEPSY OF THE INSANE.
In  studying  epilepsy it is  well  to  remember  the
various causes which may  operate  to  produce this
distressing and paroxysmal condition.  These may be
such as brain abscesses, exostosis  inpinging  upon or
into the  brain, tumours of  various  kinds,  haemor-
rhages, or some direct traumatic injury, such  as bullet
wounds in the head of old soldiers, or blows  affecting
the  inner  table of the  skull.  On the  other hand,
there  may be only  molecular  disturbance,  which
results in  epileptic attacks  by  explosive energy, or
in a discharging lesion from accumulated vital activ-
ity.  The nervous system  has  an instability in its
ultimate elements which takes on violent action irregu-
larly as would electricity if pent  up and no outlet
permitted  while being  generated.   The  two classes
or  causes  may operate  together,  or may  be  only
co-temporaneous.   A system in a state of mutability
needs little irritation—toxic, anaemic or  traumatic—
to manifest great bodily disturbance.
  Hughling's  Jackson  divides  epilepsy into three
classes, based upon  physiological  lines  rather than
anatomical divisions:
  1st. The lowest level is composed of the grey matter 
EPILEPSY OF THE INSANE.
131
of the spinal cord, and its upward  prolongation into
the brain as far forward as the oculo-motor nucleus.
This is a sensori-motor level.  This  is the first point
of resistance, and communicates with the external
world, as  well as being the first nervous depository.
It is the spinal centre of vital energy.
   2nd. The next higher  or middle centre   is also
sensori-motor,  but of  a more complex  nature, and
consequently a later organization in the evolutionary
building up of nerve structure.  This area includes
the brain sections which lie alongside the fissure of
Rolando, and along the upper margins of the  hemis-
pheres.  These  are now  said  to  be the functional
centres for specific and localized action, and possibly
include the temporo-sphenoidal lobe  as  well  as the
gyrus fornicatus.  These  areas are  one more step
removed from the periphery of the body.
   3rd. The highest centre or third level finds its nerve
activity in the frontal  and occipital lobes, being the
highest and latest evolutional development.  In each
successive section we find representation of the lower
in the order  of  building up.  As Jackson puts  it:
" All  parts of the  body are represented in the lowest
centres,  are re-represented in the middle, and are
re-re-represented in the highest centre."
   Epilepsy attacks  the  three levels  in succession,
from above downwards ; that is: (a)  The ideo-motor
centre in the grande mat form ;  (6) then the specialized
functional centre;  (c) then  the spinal  cord  centre-
They might be illustrated thus: 
132
MENTAL DISEASES.
  In Jacksonian epilepsy this order is  reversed, and
the lower resisting and accumulating centres may be
affected  without  the  higher  feeling  the morbid
impulse.  In the ordinary  gross  forms of epilepsy,
when the patient is  seized he  suddenly falls down
absolutely unconscious, and is universally convulsed ;
first becoming rigid in  tonic spasm,  then jerked in
clonic spasm.  " The organ of the mind"  is for the
time thrown completely  out  of  function  by the dis-
charge which  has taken place in it, and  which has
extended  dowTn\vards through middle  and  lower
centres.  At this  period  the  patient seems to be and
is  on  the very verge of death,  for  dissolution has
reached the very lowest level compatible  with life. 
EPILEPSY OF  THE INSANE.
133
Only those centres  concerned  with respiration and
circulation are intact, and  even these, in most cases,
are gravely disordered, and in some rare cases death
ensues.
   The spasms soon cease, to be followed by tempor-
ary  paralysis,  with a comatose  condition.  Exhaus-
tion has taken place in the three levels, and remains
so until vital  energy has  had time to  again draw
upon its resources.  This  it does  from the sensori-
reflex centre  upwards.  When cerebration is estab-
lished there may be slight  stupidity for a time, to be
followed  by normal mentality, or there may be a
maniacal condition, in which there is little or no control
of conduct.  Should this continue after the immediate
effect  of  a fit has  passed  away,  then  have  we  in
such, insanity.  The epileptic insane may  be possessed
with any of the forms of  mental disease, as  no dis-
tinct class is associated with it.  It will be seen that
epilepsy may  exist in a person without insanity.   In
fact,  a  majority  of  the epileptics  are sane;  many
business men  are  thus afflicted, and many  sons of
genius have been its victims
   One of  the peculiarities  of the mild form is that
some patients suddenly lose  their  memory and as
suddenly recover it; or,  rather, they live in a state of
double consciousness without any recollection of this
sdual existence.  Such will  wander away from home
without cause, and with  apparently ordinary intelli-
gence seek and obtain shelter and food from strangers ;
and  in this way will journey many miles from home, 
134             MENTAL DISEASES.
and  suddenly come to themselves in bewilderment as
to their  whereabouts.  Incendiarism,  manslaughter
and attempted suicide are often perpetrated in this
condition, of which  the author has no  recollection.
We see something analogous to it in somnambulism ;'
or, more striking still, in the frenzy of a drunken bout.
The  drunkard  will  destroy  his own  property, and
assault his well-liked neighbours and wife and chil-
dren with devilish cunning and ferocity.  Worn out
with his furious onslaughts, he falls into a deep sleep,
and  when  he  wakes  remembers nothing  of  his
actions, and is amazed at the wreck and ruin about
him, and will scarcely believe that he was  the  per-
petrator.   The victim of masked or larvated epilepsy
kills his family, or attempts to do so, and often tries
to commit suicide, or may  succeed in taking his  own
life afterwards.  The acts are purposeless and without
malice, usually against those who are loved best. Such
as fail in  taking their own lives,  will wander away
with apparent intelligence, and suddenly come to them-
selves without a solitary recollection of some terrible
tragedy in  which  they have  been the chief  actors.
Many of such will straggle about  in a harmless and
aimless  way for days at a  time. I  recollect  two
instances of partially recovered memory in such, but
the parties were not sure how much  was fact and
how much  was fancy, as the  mental photographs
seemed  like a horrid dream  or  a no less  terrible
nightmare.
  This temporary  amnesia which  follows the mild 
Epilepsy of the insane.          135
forms of epilepsy shows no evidence of ataxia, and
the more mild the attack the more likely are  we to
have  following  it this mental automatism.    The
same is true when mental dethronement follows the
fits.  The severe form  comes on less  frequently and
the brain has time to  recover  its  tone  between the
attacks, but in the petit rnal there are in the majority
of cases such frequent  assaults  that the recuperative
powers  are  weakened  and  the fortified centres are
more  easily  overcome.   " The  constant  drop  wears
the stone."
  The amnesic conditions thus engendered have many
methods of manifestation.  For example, a man pays
money to liquidate  a debt immediately before an
attack, but afterwards forgets  all  about it, and this
loss of memory of this act continues.  An educated
and  intelligent man feels  ill  and  confused  for  a
moment  or two.  He remembers afterward that he
ordered his  dinner at a  restaurant, but  forgets that
he ate  and paid for it in a perfectly rational way.
A man goes into a house, and while  there he  has  a
momentary unconsciousness and goes out without his
hat; but finding he has lost it commences to enquire
for it in strange houses, having forgotten  for a time
not only  that  he  lost it, but also the house he had
visited.
  I know a man in a northern town who suddenly,
on many occasions, lost consciousness while working
or talking.   Immediately  he wandered  away  from
home for days at a time a veritable  tramp.  He asked 
136
MENTAL DISEASES.
for food  and night-shelter in  a  rational  manner.
When he recovered his normal consciousness he found
himself on several occasions more than  thirty miles
from home, travel-tired  and travel-stained,  but  he
had no recollection of his various journeys.  After
treatment for epilepsy he ceased his wanderings and
has remained well  for over ten years.
  A man in this  city some four years ago  took a
hearty supper.  While sitting in his chair afterwards
a fit of unconsciousness  came  over  him.  It passed
away.   He then went to a drug store and procured
some medicine, but did not remember anything about
it.  His  memory  otherwise was good,  and  mental
impairment was not noticed by me.  He continued
his employment for a year afterwards as valuator of
property for a  large  loan company.  A number of
times  during the  year following, these  fits came  on
him, followed by the usual hiatus of memory.   At
last amnesic-aphasia set in, and was followed in a few
months by cerebral apoplexy and death.
  A clergyman who became afflicted by  loss of mem-
ory because of  larvated  epilepsy, left  his boarding
house in a western town some years ago.  He started
to visit his native place about 500 miles  distant.   He
procured a ticket at the railway station and paid  for
it  in a  rational  way.  He travelled partly by  rail
and partly by boat and  reached his home in safety.
He preached two sermons of great eloquence to the
congregation of his youthful attachment.   There was
no evidence of  mental estrangement in  his words or 
EPILEPSY OF THE INSANE.          137
conduct during  the journey  nor in his conducting
public worship.  He stated to me that he remembered
nothing after getting  up in the morning on the day
he began  his journey until one day, about a week
afterwards, he suddenly came to himself as if he had
awoke from  a  sleep of  the  most  profound  kind.
Within a year afterwards he had a number of these
lapses, which were followed by insane melancholy, and
now the brilliant intellect is buried in that  tomb of
the mind, chronic dementia.
   Here was  mental  activity  without  any psychic
record in the pigeon-holes  of  retrospective  activity.
It was as if  it had  never  been, and  yet  it was in-
telligent mind operation.  It  was not simply uncon-
scious cerebration automatically repeating  its former
actions and experience, because in this, and other such
cases as those cited, the mind provided for  unforeseen
contingencies in an intelligent manner and  along lines
of thought not  previously  travelled.   Here are two
mental states into which consciousness must enter,
one  of which  is  forgotten.   The  remembrance of
mental  conditions and  acts  which  consciousness
presents to us needs two conditions, viz., intensity and
repetition.  It is  possible these  are wanting ; hence
no cerebral registration of a permanent kind because
of cortical ennervation, consequent upon the  fit in the
ideo-motor centres.  The brain receptivity  was feeble,
so would  be the registration of impressions.  I have
not  been able to ascertain whether memory in one of
these states is able to recall the events of  a  previous 
138
MENTAL DISEASES.
similar condition.  It would be interesting to know if
the mental register can be read, and that only at these
times and under these analogous circumstances.
  I had the impression that roads formerly travelled,
or houses  visited, or people  interviewed  might  be
remembered  in this secondarj'-  consciousness when
the  brain  had returned  to  this  abnormality  of
function.
  Some authors state  this to be the  case  in  some
instances, but  my  research  has not  verified  this
assertion.   Frequent repetitions of these conditions in
the end lead to mental dethronement of a permanent
kind.
  Trousseau records  a case of a prominent citizen in
Paris, who attended a  meeting of a learned society,
went out bare-headed, walked a considerable distance
in the city, returned and took an  intelligent part in
the discussions, but knew nothing about his walk.
  Such patients may  be speaking  or  reading, and,
although  unconsciousness  may  come on  during the
mental  exercise, they  may go on and finish  intel-
ligently what they were speaking or reading about,
but  have no recollection of the matter after a certain
time.  It can easily  be  seen, then, how  suicide, homi-
cide, rape, incendiarism and other overt acts might be
and  are committed in such a condition without any
recollection of  them by any of the actors.
   Law  never allows for this  state, and  gives  little
credence to witnesses who may testify as to its exist-
ence.  They are looked upon  as merely theorizing to 
EPILEPSY OF THE INSANE.         139
allow a culprit  to escape punishment for violation of
law.
  Another form of temporary loss of memory because
of masked epilepsy is that in which there is no recol-
lection of the past of  which a person was possessed
anterior  to an attack.  I remember a  case of a sane
patient who, after a state of  mental stupor,  found
that she had forgotten a month of her life previous
to this confusional condition.  The last she remem-
bered  doing was the opening  of a gate in going to
visit a neighbour.   This lapse  also extended for two
weeks after the attack.   She told me, ten years after-
wards, that  these  six weeks of her life were  still a
blank.  This condition, in a milder  degree, had visited
her several  times afterwards.  In  such cases, some-
times  memory  returns suddenly,  sometimes slowly,
showing that  impressions, both objective  and  sub-
jective, had  been normally made,  but a dislocation
had, for the time being,  taken place  between the
ideational centre and  the reproductive power.  The
slides were in the machine, but they did not focalize
for a time.
   By  some Continental writers these conditions are
named epilepsy of the mind.   This  term is a  mis-
nomer, principally for two reasons:  (a) Such a  state,
when  applied  to mind, is  unknowable and unthink-
able ;  (6)  There is  no  doubt, if  analogy  proves
anything, that  it  is merely brain  disturbance in its
energizing  and directing  functions,  from  which
follows  mental paralysis  or mental  inco-ordination. 
140
MENTAL DISEASES.
In many cases cures are effected by the administration
of appropriate remedies, such  as the  bromides,  the
phosphides and the arsenites.  These can only produce
physical results,  showing  the seat  of the  disease ;
arid what is serviceable in severe forms  of  epilepsy
is also  indicated  in  this strange  form  of  mental
oblivion  or double consciousness, in which  is intel-
ligence, but  which carries  with  it  no capacity  of
retrospection or recollection.
  The following points are worthy of notice:
  1st. In epileptic insanity we  have  to  study  the
mental effects rather than the fits.
  2nd. Eccentric  acts  may precede  the fits, but  the
more  positive symptoms  are the frenzy,  the  irasci-
bility, uncontrollable  passion and violence, followed
by stupidity  in many.
  3rd. Although  such  are often homicidal, profane
and obscene,  yet  many of  them  have the exaltation
of religious ideas, and  are very devotional.
  4th. The mania is more intense after a few convul-
sions until it reaches a fixed standard of severity.
  5th. The actions and manners which  are noticed in
the first outburst of excitement will almost invariably
be found to  characterize all the subsequent  attacks
in the same order, although  not  always in the same
degree.   This sequence of order is  seen  in  the  pre-
monitory symptoms.   By  carefully watching these,
and using precautionary medical means, the violence
of the attack may be very much mitigated.
  6th. In  true epilepsy,  Dr. Strong,  of  Cleveland, 
             EPILEPSY  OF THE  INSANE.          141

pointed out several years ago that there is an oscilla-
tion of  each  iris causing  an abnormal dilatation and
contraction of  the pupils.  My observation confirms
this statement.  Many mendicants seeking  sympathy
simulate epilepsy with clever deception.  With such,
this sign is of diagnostic value as no malingerer could
produce this  result.
  7th. The existence of aura, or what is  called the
warning of a fit, is in reality the beginning of the fit
itself.
  8th. It is not to be forgotten  that what  we see in
the disease is only  the  secondary result of a morbid
influence working behind it.
  9th Assuming the seat of the disease  to  be in the
cortical substance of the  brain and in the grey matter
of the spinal  cord, yet  we must  take into account
what  is evident, namely, an abnormal  change in the
sympathetic nerve centres which supply tone and stim-
ulation to the arterial coats in these disturbed localities.
The hallucinations of all or any of the senses vary in
persons so that no two are  alike.   This shows that
the arterial  spasm  depends on the ganglionic centre
from  which it may receive its energy  in  various
 degrees of intensity.
   10th. In  bleeding an animal to death we have
 analogous results in  convulsions  and loss of  con-
 sciousness.  The  same  is  true  in  a  watery  condi-
 tion  of  the blood, in  albuminuria, diabetes or in
 parturient women.  Excess of urea,  uric acid  and
 poisons introduced into  the  blood  will produce  con- 
142              MENTAL DISEASES,
vulsions, which are counterparts of  epilepsy.   All
such affect the calibre of the blood vessels.  The same
is true in the convulsive state of children as seen in
the disturbance of the digestive organs, severe burns,
teething, irritation  of worms, and such like.
  11th. Strictly  speaking,  epilepsy  is not a single
disease, because it  has so many diverse  phenomena.
It is  a series of psycho-physical disturbances.   It is
not merely a succession of stages of rise, progress and
culmination as in other diseases.  The  impairment
comes from  different causes.  The  physical commo-
tion, the mental excitement, the unconsciousness, the
violence, the enfeeblement, the fixed ideas, the irresist-
ible  impulse and  want  of  volitional control  must
mean  a  congery of excitants, acting singly or  con-
jointly.
  12th. It is a  matter of surprise that such shocks, so
violent and so sudden, do not in every instance  pro-
duce insanity, yet a majority of  the epileptics never
lose  their  minds, except during  the invasion of  each
fit,  and many  of them  are  useful  citizens all their
lives.
  13th. The influence of heredity is very great in its
production.   More  females are  affected  than males
among the insane.  Statistics show that about 35 per
cent,  may be traced to neurotic inheritance.  About
76 per cent, of all cases occur before the age of thirty;
about 30 per cent, occur before the age of ten, and
nearly 50  per  cent,  between  the ages  of  ten and
twenty. 
             EPILEPSY OF THE INSANE.           143

  14th. When epilepsy comes on in early life it makes
the child either  an idiot  with undeveloped  mental
faculties, as  the  organic precedes the  psychical, or
leaves such at best imbecile or feeble-minded.
  Such usually are short-lived ; but  if they grow up
to adult life they are either irritable, morose, mali-
cious  and sometimes dangerous, or they become hope-
less, helpless and harmless, with not even the instincts
or intelligence of the lowest of the brute creation.
   It will be seen that, in a medico-legal aspect, it is
important to keep these distinctions  in mind, as on a
clear  understanding of  these  may depend  our intel-
ligent evidence as to responsibility and  mental capa-
city.   Those who are afflicted by fits in early life may
possess a considerable amount  of cunning and animal
shrewdness, but are deficient of moral attributes, and
usually gravitate into  the criminal classes of a low
grade.
   It is very  important to bear in mind certain diag-
nostic distinctions when called upon  to distinguish
between epileptic and hysterical fits.
   In  epilepsy the attack, as a rule, comes on suddenly;
in hysteria it attacks  often  gradually and  with  con-
sciousness.   In epilepsy the patient utters a scream—
if at   all—at the outset, and  only  then; in hysteria
screaming  is indulged  in  during  the course of  the
attack.  In  epilepsy the convulsion is  characterized
by rigidity,  followed by regular jerking movements
or  clonic spasm ; in hysteria there are irregular rigid
movements, and  a general throwing about of the head 
144              MENTAL DISEASES.
and limbs.  In epilepsy there is usually a biting of
the tongue from a spasmodic coming together of the
teeth;  in hysteria there may be a gentle biting of the
lips and hands, but more often an attempt is made to
bite  other people.  In  epilepsy micturation is often
present during an attack ; in hysteria it very rarely,
if ever, occurs.  In epilepsy the  patient never talks ;
in hysteria talking is frequent.  In epilepsy the dura-
tion of the attack is commonly but a few minutes; in
hysteria the duration of the fit may extend to hours.
In epilepsy of  the severe type unconsciousness is
patent; in hysteria intelligence  is often very keen,
cunningly seeking for sj'mpathy.   Of course, it is not
to be forgotten that  epilepsy and hysteria may co-
exist in the same individual.  The  one may not be
the result of   the  other, as they may  be only co-
temporaneous,  or  may, as it  were,  simply co-habit.
Then, again, they may antedate one another, or be
synchronous, and  yet  maintain independently  their
distinctive features.  The epilepsy may be the promi-
nent and  pronounced  disease,  and  it  may,  at each
attack,  be followed by hysteriform  symptoms.  On
the other  hand, the hysteria  may be  chiefly mani-
fested, followed by a mild form of  larvated epilepsy.
Often, however, the two commingle in their symptoms,
so that it is  difficult  to  distinguish which was the
primary and which the  secondary attack.  When the
two  persistently commingle, then have we hystero-
epilepsy,  often  accompanied  by  mental  alienation.
Few asylums are without such cases. 
SYPHILITIC INSANITY.
145
CHAPTER XIV.
             SYPHILITIC INSANITY.
There is  no doubt  syphilis is  a great  excitant  to
produce insanity.   It  is often difficult to procure all
the data necessary to a correct  diagnosis, but they
often crop out  months and  years after insanity has
commenced.
  The clinical features of this class of the insane may
be thus summarized.  The mental effect is an impair-
ment or enfeeblement, at first trending towards semi-
dementia, and  ending  in  total mental  deprivation.
There often are  intermittent attacks of  mania  of
longer or shorter duration.
  There is seen early  in the disease  a childishness  or
emotional weakness.  At one time fears and tears
over groundless apprehensions, and  at another time
merriment over silly matters.   The moral nature is
overthrown, and at last even the animal instincts are
lost.
  Many cases are  in  one aspect very much like those
afflicted with  paresis, and  that  is  by  manifesting
delusions of grandeur and having muscular inco-ordi-
nation.  There  is great irritability  of temper, and
capricious notions  are common,
     10 
146
MENTAL DISEASES.
  There are often aphasic  conditions, and sometimes
combined with amnesia.
  Syphilis  may  not be the cause of an invasion of
insanity even if  present.  It may only be co-tempor-
aneous with the  mental trouble.
  Two factors may be present to cause insanity, when
the effect of one of  these might not.  Syphilis alone
might not do it did there not exist an inherited ten-
dency in addition.
  Syphilis  is  often an excitant to produce disease in
the nerve elements of  the  posterior columns of the
spinal cord.   We then  may have  insanity following
locomotor ataxy. The disease spreads upwards.  The
bodily features  are so  mutifarious that it is difficult
to even classify  them.
  The most prominent are :. (a) Convulsive and para-
lytic  motor symptoms; (b) these  usually  take the
form  of hemiplegia, palsy  of  the  cranial nerves, im-
pairment of inhibitory power of a wide-spread nature ;
in short, a general paresis, not paralysis,  (c) Epilepti-
form seizures, clonic and tonic spasms, tremors which
imitate chronic  paralysis agitans.  (d) Local numb-
ness at one  time, and at  another intense nocturnal
hemicranial pain,  (e) The special senses  are  fre-
quently more or less  affected, and optic neuritis is
very common as well as unilateral deafness.  These
defects lead  to hallucinations  and delusions  from
which often spring unfounded  suspicions of friends
and a fear of  conspiracies.
   Many of these symptoms are not pathognomonic of 
               SYPHILITIC  INSANITY.             147

syphilis, as they are common to other forms of insan-
ity ;  but if persistent nocturnal hemicrania, giddiness,
epileptoid fits, unilateral spasms and pains and local
paresis exist, our  diagnosis as to the syphilitic origin
of these will usually be correct.
  At the same time, we are not to neglect to look for
characteristic  glandular disease, ulcers of the skin,
nodes, and disease of mucous membranes.
  Those persons in an anaemic  condition are more apt
to become excited and maniacal.   This  condition is
usually of short  duration, and may be followed by
melancholia, as  an intermediate  step to  dementia.
The  premonitory symptoms  may be  an  attack  of
apoplexy   or  epilepsy.   A  general depreciation  of
brain tissues takes place.   It  may  be  atheromatous,
gummata, or sub-acute meningitis.  As a rule, how-
ever, the  atheroma,  which consists of hypertrophy
of the  brain  arteries and  which  goes on  to  fatty
degeneration and calcification, is not present.
  The anterior cerebral  arteries are chiefly affected.
  The syphilitic condition is seldom found in nerve
tissue proper, except  in the  form of softening from
deficient blood  supply,  consequent on the reduced
calibre of  the blood vessels.
  Fibrous tissue, lymphatics, arteries, membranes and
the  skull   bones  are primarily the  seat  of diseased
changes.
  The  retrogressive change  in the  arteries is  quite
distinctive.  The adventitious membranes formed in-
side  the arteries are firm and tenacious.   So much so, 
148              MENTAL DISEASES.
that in the larger vessels they can be removed entire,
as if from a mould.   This means reduced size, and in
many  of  the smaller  arteries  occlusion.  It is  no
matter of surprise,  then, that  serious physical and
mental deterioration  follows these extensive lesions.
Brain syphilis is interesting, like paresis, because we
find characteristic  physical  changes, about which
there can be little or no doubt as to their cause.
  Insanity does present itself  in  the first stage of
syphilis before  much pathological change can  take
place in the great nerve  centres.  It  is  possible that
in many such cases the shame, contrition  and moral
sensitiveness  in many natures  may, at  this  early
stage, be more causative than any such toxic agent.
  In the period of secondary syphilis a large number
of this insane class are attacked.  It then produces a
sub-acute condition, and the mental state is usually
that of insane melancholia or a mild form of mental
exaltation or excitement.
  In  the  tertiary  period  we  have the  pronounced
signs and symptoms which have  been  already enum-
erated.
  The neural  changes account  for the  varied delu-
sions, the  characteristic hebetude and  the  general
depreciation so pathognomonic of this disease.  These
cases are  very  difficult to  treat,  often  because of
uncertainty in diagnosis in the early stages, but  they
are often greatly benefited by the use of anti-syphilitic
remedies, 
ONANIC  INSANITY.
149
CHAPTER   XV.
               ONANIC INSANITY.
This vice of masturbation may begin with both sexes
at an early age.   At the age of puberty great  physi-
cal and mental changes take place.   The development
of sexual vigour and desire is accompanied by corres-
ponding  mental  activity, not  only along  the  old
lines of thought, but also in the wakening up  and
growth  of appetites and ambitions,  which,  when
rounded up in normal  outgrowth,  constitute an im-
portant element in the make-up   of  the womanly
woman and the manly man.  There is here a connect-
ing link between the animal instincts and the  higher
faculties of the mind.  The weak-minded, the  idiotic
and human monsters often show genital defects or want
of development, although such  may exhibit erotism.
The brain  sometimes excites to sexual attempts which
are incapable of realisation, just as  we see  in some
stages of  senile  decay,  when  the  old man cannot
realize that he  is fatally  attempting  to blow  into
flame the dying embers of passion, forgetting that in
old age " desire shall fail."
  We know what a great change  morally and men-
tally takes place, as  a  rule, in the eunuchs.  Castra- 
150              mental Diseases.

tion seriously affects animals, so veterinary surgeons
testify.
  Such  being the case, it is not difficult to understand
that  onanism  and  inordinate venery will  produce
mischief on the genital organs and through them on
the whole system  because  of  the undue  excitement,
great demand on secretion, and as a resultant, lower
vitality  even to impotency and mental  failure.
  It has been said by some writers that no harm can
come from the uee of organs along natural lines;  but,
on  the  contrary, benefit as against continence  and
restraint.  It is forgotten  that any excesses are  not
natural, but  are  abuses of normal  function.  Self-
abuse is unnatural,  hence  unhealthy and disastrous
to mental integrity.  Not only so, but it  can and is
indulged in  by over-stimulation at  least five  times
oftener  than natural  capacity  could  permit.   This
means a great strain on the nerve centres, which are
roused to undue  activity by  artificial means.   The
moral effect is shown in these  victims,  and it is disas-
trous to their offspring.   The mother may be strong
and healthy, but if the father is not capable of pro-
ducing  a vigorous  spermatozoa the result means a
degenerate progeny.  The  soil may be good, but  bad
seed  means   a  poor crop.   The horrible orgies in
Pagan and Christian countries  arising out of sexual
perversion show how its influence controls all mental
attributes.  This is strikingly true of the insane with
erotic tendencies.  There is no specific type of  insanity
among masturbators, but they usually gravitate into 
ONANIC INSANITY.
151
dementia in the end.  After the insanity in the form
of stupor takes place desire becomes in many largely
extinct, and although  there may  exist spontaneous
emissions, the habit is seldom indulged in, but at this
stage the mischief has been done.   It is not to be for-
gotten, however, that  this vice may be only a result of
insanity, arising  from  a cause foreign to the habit.
Erotic insanity,  the  prurient-paretic, the delusional
patient, and the shameless, beastly insane may become
onanists after  brain  disease has set in.  The moral
barrier is broken down  and the animal instincts have
the ascendency.  A  great  many  epileptics become so
from this cause or from venereal excesses, and continue
the  habit after the  fits have been established.  The
epileptics are usually very religious in their own esti-
mation, vice or no vice.  In fact, many of this class
lay great claim to piety, and would look with horror
on fornication, but  compromise  with  conscience by
indulging in this " enshrouded  moral pestilence."
   The beginning of  this vice  is  usually by example,
especially among companions at school.  Often  it is
accidental and arising from the awakening feeling at
the pubescent age.   When many realize how hateful
it is and what  direful results  so often  follow  the
practice, they have  sufficient will-power to refrain
from it, and if not long indulged in, no evil results of
a permanent nature may follow.   It is needful to say
this plainly, not to minimize the  evils of the vice, but
because the after lives  of such  youths are often made
miserable through their falling into the hands of the 
152              MENTAL  DISEASES.
lying "specialist," so-called, and "nerve doctor," whose
advertisements defile our  walls and newspapers, and
whose foul pamphlets find their way into respectable
homes.  All masturbators do not become insane, and
no cure can be affected by merely taking medicine if
the habit continues.  A great  majority of beginners
will recover from  the primary  malign condition by
simply refraining from the habit, without taking the
nostrums which are so persistently  urged  upon  their
notice by quack pretendors.
  If there should exist in  the constitution a tendency
to any  nervous  disease or  to insanity, then  such a
vicious habit will precipitate a manifestation of the
latent  untoward  heredity.   It  rouses  into action
diseased states which otherwise might have remained
innocuous and latent.  It is simply a spark put in
the magazine of powder, which, otherwise, is as harm-
less as  a  pile of  sand.   Such victims,  before  they
reach asylums, often go to medical men for advice in
a neurasthenic condition.   They are usually anxious
to know if they have not  heart disease, dyspepsia or
some  form of nervous trouble.   They  complain of
sleeplessness,  nocturnal  emissions,  pain in the  back
and legs, dull  headache, confusion of thought, partial
loss of memory, desire to weep from low-spiritedness,
anxiety to  be alone, little care for any society, poor
appetite, sallow countenance,  often  hectic   cheeks,
horrid and lascivious  dreams, and  a general lack of
mental  and physical  energy.  Such may  be  typical 
ONANIC INSANITY.
153
cases  of  sane victims,  but  on the  borderland of
insanity.
  The next step in the downward direction is seen in
a pronounced case.  For example:  He is very shy; he
has an  evasive  and cast-down  look and a dull and
irresolute character, inconsistency of demeanour ; he
is subject to all  kinds of suspicions and  imaginings.
Self-accusation and even fanatical notions prevail of
a childish nature.
  We find in such, very often, irregular circulation,
the hands cool  and   clammy,  the  head  hot,  more
especially the neck and  back of the head, biting of
the nails, scratching of the fingers, restlessness of the
body, carelessness to  appearances and  surroundings,
loss of  natural affection, want of  concentration of
thought, delusions, and, last stage of all, melancholia
to be  followed by semi-dementia and  permanent in-
sanity.   Friends bring such  patients to hospitals  for
the insane, and,  if questioned as to what they know
of the existence of such habits, grow quite indignant
at the insinuation and burst out into  eulogy on the
good  morals  of the  patient.  " He  is  so  shy, so
retiring, so modest, so pious, so obedient, and so fond
of solitude."   The  father and mother think  he is a
model of propriety and goodness.   Do not take such
a catalogue of all the virtues at par, if such symp-
toms  as have been enumerated are present.  The fond
relatives expect  he will soon  be well and  get home;
but, as a rule, it is a vain hope,  for, even if the  habit
should be stopped, the mischief has been done.   The 
154             MENTAL DISEASES.
constant and unnatural drain upon the nervous system
has produced  such brain changes  as  to assume a
chronic form before we see the patient.
  Here we  have  a  demoralized  and  deteriorated
character.    He  may  have  been  manly,  truthful,
vigorous and trusty ;  but now his  moral nature is
wrecked.  Occasionally there are outbreaks of mania,
based on delusions;  sometimes a stubborn melancholia
is present; sometimes  a stuporous condition sets in,
or,  rather,  it  might  be called psychic inertia—all,
however, mean mental unbalance and lethargy.
  Many examples of such have been presented  from
session  to session  to  the classes called out  of   our
wards;  and the majority of them had been intelligent
and bright young men, but they have made shipwreck
of  their lives, for "their pleasant vices have scourged
them."
  It has been  my experience of such cases that  the
most of them come from those  classes who have little
outdoor or physical exercise;  in  other  words,  from
among those of sedentary habits.   Hence, in  rural
districts, and among  the more  robust  and healthy
farmers and mechanics,  this  disgusting and  filthy
habit  is not  practised  to the same extent as among
the weaklings  and prurient classes of our towns and
cities.   Many physicians recommend marriage  as a
remedy.  This is a grievous mistake,  and involves
mischief and unhappiness to two persons.  The man
who, because of this  vice,  dislikes women, will  not
make an affectionate  husband to  any woman  until 
ONANIC  INSANITY'.
155
his manhood is restored;  and he will be an object of
disgust, in his impotency, to any virtuous and healthy
woman.   Not only so, but  he bequeaths a heritage of
degeneracy to his children  in one form or another, and
adds  his quota to  the  already great  army of defec-
tives.  The innocent descendants suffer for sins which
they did not  commit, and  often curse the authors of
their being when, in adult life,  the truth becomes
known to them.
   In  treatment,  many are the rules  set down  for
guidance.  It is  useless to stuff such with medicine,
give moral precepts, or scold them like a fish-wife, if
the victims  have not honestly set about reformation
by their own efforts.   This co-operation is essential to
recovery.  If they do not  really wish to conquer and
forsake  this vice, help and encouragement are alike
vain.  They choose and seal their own fate  in the
face of  the knowledge of the consequences.
   I think it is Whittier who truthfully sings :

            " The tissues of the life to be
               We weave in  colours all our own,
              And in the field of destiny
               We reap as we have sown."

   At the same  time,  these victims  can be assisted.
Tonics may  be  given in  such cases, if anaemic  or
neurasthenic, but  not such  as strychnine  or any
spinal  excitant.   The  physical  treatment is  given
elsewhere in this  manual.  These  unfortunates are
not to  be discouraged, but urged to  abstinence by 
156
MENTAL DISEASES.
holding out every good motive to  stimulate  them to
make efforts for their own deliverance.

                 The Insane Ear.
  Hcematoma Auris (Orthoematoma).—It  is an effu-
sion of blood under  the perichondrium,  between  it
and the cartilage of the ear.   It  may come on in a
few hours, or gradually, and at first swells the exter-
nal ear to a great size.  After a time the swelling
subsides, and leaves a mis-shapen ear, being shrivelled
and withered, and often, but not  always, of  a  bluish
appearance.  It is then only condensed tissue, but at
first it consists of a bloody, gelatinous substance.  So
tense is the skin that it shines, and is very smooth
in the acute stage.  It is  hard and painful on slight
pressure, but when more firmly pressed a fluctuation
is felt.   Sometimes it breaks, and a sero-sanguineous
fluid is discharged,  The swelling is confined  to the
concave surface of the penna.
  These and  such-like facts indicate that in the great
majority  of  cases  it is spontaneous,  and  indicates
arterial degeneration of the terminal branches  of the
posterior  auricular artery.  There is  also  present a
deterioration of the  vaso-motor fibres of  the cervical
sympathetic.  This  passive condition  is  not  to be
mistaken for acute  perichondritis, nor for cysts and
tumours,  which often grow in the substance of the
external ear.
   Did we not  allow for these diseased conditions  as
existing,  rather than traumatism as the  sole cause, 
ONANIC INSANITY.             157
then would it  be impossible reasonably to  account
for its absence in such  a large  number of sane and
insane who have  injury of the  ear inflicted without
producing such results.
  The usual treatment is by the  application of  con-
tractile collodion  three times a  day.  A combination
of collodion, oxide of zinc, and a  few grains of carbolic
acid made into a  paste have  been  highly recom-
mended.
  The lesion is only present in the cartilaginous  por-
tion of the auricle.
  It may be that injury  from  falls or self-infliction
from  tugging  at  the ear, or a slap from  the hand
of a rude attendant may be the occasion, but not the
cause, of haematoma auris,  the cause being in  the
pathological  state of the parts which violence  may
sometimes  make   manifest.  Some  reasons  for  so
believing are as follows, viz.: In the  first  place,  it is
seldom or ever seen  in acute mania, when injury to
the body, including the ear, so often takes place.   In
the second  place, it is  seen most frequently in  the
left ear, but if  traumatism were the  principle cause,
there is little reason to believe  that  this selection of
the left  ear would so frequently take place.  In the
third place, men  are  more  subject to be afflicted in
this way than  women,  yet  the  latter are  more rest-
less  and excited  than  men, and more  likely to  be
bruised,  and  are  more  trying to  the temper  and
patience  of women nurses than are  the  men to  the
men nurses,  In the fourth  place,  it is very prevalent 
158
mental diseases.
only in  certain forms  of  insanity.  It is  very com-
mon among epileptics, chronic  maniacs and paretics,
but is not often seen in dementia or in the paranoiacs.

                    Katatonia.
  Katatonia is said to  be  a brain disease  which has
alternations somewhat similar to circular insanity,
with more variety.   It ranges  through the different
phases of simple  melancholia, mania and a stuporous
condition merging on dementia.  In addition to these
there is found a convulsive  and cataleptoid  state.
Kahlbaum,  in 1874,  claimed  that,  clinically, these
symptoms  indicated  a  distinct  form  of insanity.
Many thus  afflicted have  also  a  stage of  exaltation
with logical and fixed  delusions,  such as are  seen  in
primare  verrticktheit.   Alienists have differed as  to
its being a newly-discovered disease, but the  prepon-
derance  of  opinions  lead to  the belief that it can
fairly be classified under other forms  of  mental
disease which  are similar  in etiology, with  catalepsy
and convulsions superadded. 
PARANOIA.                 159
               CHAPTER  XVI.


                   PARANOIA.
Paranoia is called by many authors a monomania, so
it is well to speak of it here.  It has been given a
distinct place in the more recent literature of insanity,
so it  is  necessary to give a few details in respect to
it.  The  name  is  old  and  is a Greek word,  which
denoted insanity of all kinds in classic times.  It was
so used by  CEschylus,  Plato, Aristotle and Plutarch
(napavoia).   Esquirol  used' the word  over  sixty
years ago to mean monomania  with  delusions of
grandeur, to which the term megalomania is sometimes
applied by  the  French.  Griesinger used it in 1845,
but added to the grandiose delusions those of succes-
sive delusions of persecution.  In 1852  Morel saw in
it  a  systemized form  of  delusions  in which were
logical sequents admitting the premises.
  At  first it was supposed to be a secondary disease
following mania and melancholia.  This contention is
now given  up by many,  hence  the German  name
Primare Verrticktheit, although a number  believe in
both a primary and secondary variety.
  Some thought, and some authors now think, that it
js always a hereditary disease, at least it only appears 
160
MENTAL DISEASES.
in those predisposed to insanity ;  or, in other words,
have the insane neurosis.
   I could  quote at least half a dozen well-known
authors of Continental Europe who class  under this
term all sorts of delusional insanity.
   Here is  a partial list  taken from a few  of  these
writers.   Such  as  puerperal  insanity,  post-febrile
insanity, alcoholic,  morphinic insanity, semi-insane
neurosis, such as insanity of doubt, fear  of certain
localities  (agoraphobia  clautrophobia,  topophobia),
dipsomania, pyromania, kleptomania,  homicidal and
suicidal impulses and  other  forms of insanity, with
distinctive outer oppi rigs,  are classed under  the one
name, called paranoia.
   Some authors describe this mental disease  as being
characterized by logical  or  systemized delusions of
persecution and self-exaltation without excitement.
emotion or impairment of memory.
   This disease may be hereditary or non-hereditary,
chronic or acute, primary  or secondary.
   As  Dr.  Carter Gray puts it,  the  clinical  history
shows, when it  is fully developed, the patient full of
suspicion.   He misinterprets everything to have some
covert meaning against himself.  " Trifles light as air
become as proof of Holy Writ."
   Othello's jealousy is an  excellent picture of what is
often  seen.  People are watching him, he  thinks, on'
the street  and  in  public  conveyances;  somebody
coughs as he passes by and immediately  he believes
the cough has some secret meaning;  a match lies before 
PARANOIA.
161
his feet  as he goes along the street and  he checks
himself and  goes  around it, convinced that  there is
some design about it; his wife fastens a handkerchief
in the window to dry, and he at once rushes to the
conclusion that this is a signal set for some paramour
or a headline in the paper, a bill-poster in the street,
a sign over the store, a casual glance from a passer-by,
an advertisement—each may have a fantastic meaning
lurking in it  to his  distorted  perceptions.
  As  time passes, these  delusions  become more and
more fixed.   The patient, perhaps, reasons about  them
calmly ; and  they  differ from the delusions of melan-
cholia and mania in the fact that any agitation in the
patient  is produced  as  the consequence  of  these
delusions, and the  excitement does not precede the
delusions, as  in the other forms of insanity.
  As the delusions  become more and more fixed,  there
gradually arises a  question  in  the morbidly logical
mind  of the patient  as  to  why he should  be thus
persecuted, and out of this, in a natural enough  way,
gradually grows the delusion of  self-exaltation, or the
delusion of grandeur, as the French say.  The patient
then becomes, in his own estimation, a person of im-
portance either because of  his station in the  world or
because of his personal attributes;  hence these perse-
cutions through jealousy.   One  patient will  tell you
that he is persecuted  because he has a valuable secret,
like the Keely-motor scheme,  which he  refuses to
divulge.
  Another is watched, and even  his food is  poisoned
    H 
162
MENTAL DISEASES.
to get him out of the way, because he is the custodian
of financial secrets  which would control the  stocks
and  markets, or possesses state secrets  which  would
shake dynasties to their centres, were he to speak out.
  Another has  mental  power to read  all  human
thought, and  thus he knows  his enemies  from his
friends by intuition.
  Another may  be  deprived of  his rights  by his
enemies  of  some  estates or prerogatives, which  he
will  minutely describe, with a good deal of logical
sequence and with great  earnestness.
  Infinite in working as is the human mind, so myriad
are the phases of exaltation and self-importance.
  The judgment, the  reasoning power, and the memory
of these paranoiacs  are  remarkable;  indeed, often
startling.  So  that they are  almost certain to impress
the lay observer, and many physicians also, as being
perfectly sane, except upon unimportant points.
  I have had educated men and women of  this class
discuss abstruse subjects in a connected and  even
lucid way, yet in the line of their delusions.
  In  fact,  their delusions  approach the  nearest  of
all the insane delusions  to  the fixed and erroneous
beliefs of the  sane, for they will reason about them
logically, but  will  not  be  persuaded as  to their
unreasonableness.
  Between their delusions  and the  fixed  beliefs of
the sane,  however, there lies  this great difference,
namely, that  the sane do not have the  predominant 
PARANOIA.                  163
and  unfounded  delusion  of  persecution,  mingled,
sooner or later, with that of absurd self-conceit.
  In a scientific sense or  in a clinical sense,  these
patients are not responsible.
  They may, parrot-like, state that  they know  the
nature and  quality  of their  acts as  jurisprudence
requires, and what the punishment may be for viola-
tion of law,  yet  it is evident to the  most superficial
observer that they do not really appreciate what they
are doing  because of  their lack of moral sense, and
because of the manner in which the mind,  as a whole,
is warped by the  fixed and dominant delusions of
persecution  and  insane self-exaltation.  They  are
dangerous  lunatics, and should not be at  large.
  There'is a class of them who glory in the notoriety
which litigation brings, and, if such  can find lawyers
to take up their cases, they will prosecute and perse-
cute at the same time.  Win or lose, they will press
on  to  the  bitter end.   Of  course, the morbid idea of
being  ill-used lies  at the  bottom of this mania for
law-suiting.
   This disease is often accompanied  with hallucina-
tions, and  often illusions, and from the clear descrip-
tions  which  are given of them  they must be very
vivid and distinct.
   Paranoia may arise in four ways, as  Clouston puts
them  in respect to monomania,  which  he holds is
the equivalent:
   1st. It is a gradual evolution out  of a natural  dis-
position :  a proud man becoming insanely proud, or a 
164              MENTAL DISEASES.
suspicious  man passing  the  borderline  of  insanity
with his suspicions.
  2nd. It may remain  as a permanent  brain  result
after mania and melancholia.
  3rd. It may follow alcoholic and syphilitic poison-
ing, injuries to the brain, sunstroke, and such like.
  4th. From perverted  organic sensations  and  local
diseases misinterpreted  by a weakened brain.
  There are three principal varieties :
  1st.  With delusions of  unseen agency,  suspicion or
persecution.
  2nd. With delusions of personal exaltation.
  3rd. With delusions of perverted sensations.
  When a single morbid impulse or delusive  suspicion
exists, then it becomes an  imperative conception, and
dominates the whole being.
  Diagnosis  from mania in  the consistency of the
delusions and their logical sequence.  The  emotional
nature is kept in good control, and  there is  little
motor restlessness as is  seen in mania.   From melan-
cholia, in the absence of  a sense  of ill-being, in the
absence of  insomnia, in the absence  of the character-
istic  face-lines of the insane melancholy, in having
no suicidal  impulse,  and little, if  any, confusion of
mind  to which we would give the term  nonsensical.
  Distinguished from paresis in the absence of those
motor  and  psychic  signs and  symptoms  found in
paresis, especially in respect to the reflexes and tremors
so abnormal in a paretic and yet so characteristic. 
PARANOIA.
165
                   Treatment.
  All kinds of drugs  have been recommended, but
you must be  guided largely by the  condition of the
patient as to the  use of sedatives and tonics, such as
opium,  hyoscyamine  and  hyoscine, including  the
bromides.  These may be helps, but trust  largely to
food and fresh air.  The prognosis is bad in all.
  Out of the  delusions  of persecution  necessarily
grows the necessity of action  to protect themselves
from  the persecutors, hence assault and homicide.
  In this respect  they differ radically from the melan-
cholic, who passively suffers the injury that is being
done him, and which he attributes to some sin, fault,
or shortcoming of his own, and not to others.
  The egotism and delusion of  the  paranoiac are
entirely different  from  the delusions of those maniacal
who are simply terrified, and proceed to no logical or
connected acts, but only occasionally  to  impulsive
ones, which is not the case in Primare Verrticktheit.
  I might observe,  in passing, that  the German term
of Primare Verrticktheit corresponds in meaning very
well with our English word "cracked," or  the  Ameri-
can  word  " crank," or  the Scotch  word  " a  little
daft."   It means,  literally, " shifted out  of  place."
In other words,  it is  an abnormal condition  in  a
definite line of conduct, but is  a shifting from  funda-
mental sane  mentality.   These  constitute  the  most
dangerous class of the  insane.
  The deeds  which they commit are the  dangerous 
166              MENTAL DISEASES.
deeds of deluded patients, who are yet possessed of all
the intelligence which can concoct dangerous plans and
stratagems.   The history of the world is full of brutal
murders  that have been committed  by this  class
without fear and without remorse.   Their delusions
are so fixed, and their intellects  otherwise  so keen,
that  there is no safety but in  asylum or prison  cus-
tody and supervision.  As a matter of fact, it is not a
distinct phase of insanity.  Neither  its clinical  his-
tory nor its aetiology points  to its  being any  more
than  a form  of   delusional   insanity, having   two
features prominent, viz., that of egotism and that of
delusions  of persecution.   These abnormal features
are seen in various  forms  of mental disease.
  A  medical witness who would attempt to prove the
existence of such a disease, is usually held up to sar-
casm and scorn as a hair-splitting theorist. 
PHTHISICAL INSANITY.           167
CHAPTER XVII.
           PHTHISICAL INSANITY.
Lung disease is  very prevalent among the insane,
especially the tubercular form of it.   It assumes  the
form of latent phthisis.  In one member of a family
may be  seen dementia, and  in another  mania  or
melancholia, to end in death by lung disease.  During
this disease, when intermittent mania supervenes, all
the most prominent  symptoms  of the disease dis-
appear, only to return again when the maniacal attack
has passed over.   Sometimes  mania and consumption
are cotemporaneous; but, as a rule, the latter succeeds
the former.   Very often the intellect improves before
death ; but a majority go into dementia,  if the disease
should happen to be lingering.  As a rule, however, a
majority die within  three years, and most of them
within six years after the invasion; about one-fourth
die within  twelve months.  In latent phthisis there
is seldom cough  or expectoration. The hectic fever,
the symptomatic diarrhoea and  glittering eye may be
present, with dyspnoea and night-sweats.   The lungs
are filled with miliary tubercles.
  Savage says: " Whatever in the future may be shown
to be the relationship between bacilli and phthisis I 
168
MENTAL DISEASES.
am sure there will be proved  to  be a very distinct
connection between some low  forms of lung  inflam-
mation with destruction of tissue, and death, and dis-
order of the nervous system."
  In  the sane the  hopeful  side is usually  seen, and
such are expecting to recover  if only they could get
rid of some little cough.
  The consumption in the insane is usually found to
be associated with  melancholy   As a rule this  is
associated with  morbid  suspicions of one  kind or
another.   Very often there is a refusal to take food.
Sometimes this  is  not from   want  of appetite, but
from  a  dread or apprehension that there is filth or
poison in it.
  There are  often  near   the end diarrhoea  and
haemoptysis, hallucinations of taste, smell and hearing,
with delusions of persecution.
  In short, to sum up, it may be said:
   1st. Phthisis kills a large number of insane patients.
  2nd. It is  associated with  neurotic  taint,  which
produces highly unstable nervous systems.
  3rd. In  the insane it is associated  with  certain
groups  of symptoms characterized by suspicion and
refusal of food on the one hand, and with masking of
the physical symptoms on the other.
  4th. Degenerative lung disease is common in melan-
cholia and general paralysis.
   5th. Sanity not uncommonly returns before death
in phthisical lunatics, and some recover sanity to die
in a year or two afterwards of  phthisis. 
PHTHISICAL  INSANITY.
169
  6th. Glandular disease  from trophic deficiency is a
generic term which may include such morbidity as is
found  in  the insane, the consumptive, the victim  of
kidney disease, heart trouble and such like.   We are
never to forget the reflexes.
  The frequency  of  phthisis in  chronic  insanity is
the strongest proof that mental disease has masked
trophic causes.
  The frequent association of the depraved  nutrition
known as scrofula  with idiocy  and congenital imbe-
cility has long been  known.  Perhaps two-thirds  or
even more are of the  scrofulous constitution.
  This class of defectives  is very often of  the stru-
mous diathesis, having weak circulation, a low tem-
perature, a pale complexion, bad and badly set teeth ;
the glandular and mucous structures being especially
liable to disease.
  The likeness of idiocy and secondary dementia  to
each other trophically is in many ways marked ; and,
therefore, it  is not a matter of surprise that so many
patients suffering from both states fall into consump-
tion and  die.  Fully two-thirds of all  idiots die  of
phthisis.
  The question arises: is  not  idiocy  itself  another
though a rarer, manifestation of this diathesis ?
  " It is remarkable," says Kolk,  " when in the very
same family some of the children suffer from mania
or melancholia, and the brothers and sisters, who have
remained  free from these diseases, die of phthisis.   I 
170
MENTAL DISEASES.
have noticed that a great many epileptics die of con-
sumption, especially if the epilepsy end in dementia."
  In all it is trophic failure.   This leads to the forma-
tion of the right nidus, without which the tubercle
bacillus would be perfectly harmless.
  The soil is ready for the colonization.
  Pathology finds no  distinctive evidences in  the
brain beyond general anaemia of the brain, with more
or less atrophy of the  grey matter;  we find very
rarely any tubercular deposit in the brain.  Now and
then there is local softening in the white substance.
In  short,  the brain is  shown to  be throughout  an
ill-nourished organ.

               Homicidal Insanity.
  This is the most deplorable of all  the forms of
mental alienation.  Some have been  sent to  us by
courts, having been held to  be irresponsible because
of insanity;  others have been sent  to us as insane
without a formal trial.
  The  insane with homicidal impulses  are usually
divided into  six classes, each  indicating  a difference
in mental condition:
  1st. Those who take life in a paroxysm of insane
passion or fury.
  2nd. Those who commit homicide from  delusion, or
who are deceived by their hallucinations, illusions or
disordered imaginations.
  3rd.  Those who  kill  indiscriminately,  and appar-
ently from a mere love of taking life;  that is, from a 
PHTHISICAL INSANITY.
171
diseased  propensity  and  intense  desire  to  destroy
others, against which act neither reason nor conscience
remonstrates.
  4th. Those who kill without any apparent motive,
but from  a sudden  impulse, of which  they are  not
conscious, and who retain  no recollection of anything
which prompted them to the act nor of  the act itself.
These are usually epileptics.
  5th. Those disposed to commit the same crime and
without motive, from an irresistible impulse, of which,
however, they are conscious, and against which reason
often remonstrates.
  6th. Those  who kill  from imitation, or  from  an
insane love  of  notoriety.  As  a  rule, this class is
composed of imbeciles or paranoiacs.
  In  this  connection it may be well to state  what is
meant by imperative conceptions  or dominant ideas
without  delusions.   Poe,  the poet,  knew full well
what they meant, and called them  in  an essay of his,
"The imps of  the  perverse."   We  all know, in a
rudimentary way, what they mean.   An old song or
its music, or both, spring into memory in spite of our-
selves, and no  mental effort of  ours will  drive them
away.
  By the law of association, some  long-forgotten face
or deed, or idea, suddenly  jumps into the conscious-
ness,  and  flicker in and out among our reminiscences,
like an ignis fatuus, without  our bidding, and go
from  our recollection, for the  time,  as suddenly as
they appeared.  No  force  of will can drive them away. 
172
MENTAL DISEASES.
  Let this condition, so evanescent in the sane, become
fixed in the insane as a permanent  state of  morbid
mental phenomena, and  we have imperative  concep-
tions, which control action and determine conduct.
  You will remember that the celebrated Dr. Johnson
tells us that he had an impulse to touch  each  post as
he walked along the street.  This dominent idea was
so strong in his mind that if, perchance, he accidentally
passed one by without the usual tribute  of a touch,
he felt irresistibly compelled to  return and repair the
omission.
  The overwhelming impulse to laugh  on occasions
of peculiar solemnity is one which  even  the most
serious persons have experienced.
  A still more marked instance  is that  which some-
times urges  pious people to indulge  in blasphemous
or  profane  language.    Such   tormented a  great
English divine, Bishop Butler, who only mastered  it
by  strong  and  sustained efforts of the  will.  The
imperative conception sometimes assumes a  suicidal
form, from whieh there is  often no relief.
  Dr. Ball, a French alienist, writes  in  L'Encephale
that he was consulted  by a young  man who was
engaged to  be  married, but who found it impossible
to visit his intended  bride because it  would  involve
a journey  of some length in  a  railway  carriage, and
he  could never enter one without feeling a desire  to
jump out  as soon  as  the  train was  in  motion. He
was advised to  accustom himself gradually  to this
mode of travelling by taking short journeys  on the 
PHTHISICAL INSANITY.
173
suburban train, but he could not get beyond the first
station.  There he had to leave the coach for fear of
accident.
  It is not difficult to comprehend  that  were these
intruders  to control our conduct to any great extent
we would be insane, or on the borderland  of insanity.
In these we have a faint idea of how overpowering
such  imperative  conceptions  must  be with insane
constancy and reiteration.
  Homicidal imperative conceptions  are likewise met
with.
  Thouviot tells  us he was tortured with a  burning
desire to kill some woman, but never felt the slightest
wish to take the life of a man.   He battled with  the
impulse for years; but,  at length, it overcame him.
One day he murdered a young girl, a perfect stranger,
whom chance  threw in his way, in the kitchen of a
coffee-house.
  Dr. Bell cites  the case  of  an artist, who was  a
victim of  a murderous  imperative  conception.  He
married early  in  life, his family was large, his cares
and anxieties many in proportion.  When thirty-eight
years old, without any physical ailment apparent or
any specially unfavourable turn to his affairs, he began
to be thus affected mentally.  If he  saw a mirror  he
desired  to  smash it ;  near a window he  felt  an  im-
pulse to jump out; he never got a banknote in his
hands  that he did not  feel  inclined  to tear it  to
pieces.  These imperative  conceptions presently as-
sumed a more formidable shape: he began to  be 
174
MENTAL DISEASES.
assailed with an impulse to strangle his children.  His
little  daughter  was dying  of  croup,  and  he spent
night after night by her bedside nursing her with the
utmost  tenderness: " Yet," said he to his physicians,
" at the moment when  I was praying, with tears in
my eyes, that the child's life might  be spared, I was
tormented with the horrible desire to take her out of
the cradle and throw her into the fire.  Even now,"
he added, " as I  speak  to you, I feel a most  intense
desire to strangle you, but I check myself."   He  was
a  man  of  powerful build.   He  would  have  been
dangerous had his sanguinary impulses proved to be
beyond  his control.
   No bad results followed his impulses, as they were
successfully checked.   His nearest friends did not
suspect  that  he was subject to them, as he fulfilled
all the duties of  life in an exemplary manner.
   I have often  thought  of the  horrible  doings of
" Jack-the-Ripper" in  relation  to depraved  women
only, and the uniformity of his dissections  upon this
class of  people.
   It is  to be remembered,  that when an imperative
conception forces to action it  has passed into  an
" imperative impulse," and is uncontrollable.
   An imperative conception,  like  hypochondriacal
fancies,  reminds one of  what poor Lamb sings:—
             " Crowding my privacy,
               They come unbidden,
               Like foes at a wedding,
               Thrusting their faces
               In better men's places ; 
PHTHISICAL  INSANITY.
175
               Causing confusion,
               Figments heretical,
               Scruples fantastical,
               Doubts diabolical."
  Leslie, in his life of Washington Allston, records :
" When Allston was  suffering extreme  depression of
spirits, immediately after  the death of  his wife, he
was  haunted  during  sleepless  nights  by  horrid
thoughts, and he told me that diabolical imprecations
forced  themselves into his mind."  The distress to a
man so sincerely religious as Allston may be imagined.
  He  wished  to consult Coleridge,  but could  not
summon  resolution.  Leslie, therefore, saw Coleridge
for him.   Coleridge said:  " Allston  should  say to
himself, ' Nothing  is but my will.  These thoughts,
therefore, that force themselves on my mind is no part
of me,  and there can be no guilt in them.'  If  he  will
make a strong effort to become indifferent to their re-
currence they will either cease, or cease to bother him."
  The  biographer says this reasoning was effectual.
  Bunyan  tells us he was tortured with blasphemous
thoughts of all  kinds.
  He laid them at  the  door of Satan; and, of course,
this diabolical  train of malign suggestions was an
artful  design to keep him from the true path of duty.
  They occurred spontaneously while he was praying,
preaching  or writing;  but  the immortal dreamer
resisted them, and they finally disappeared, especially
after  a  rest.   Brain recuperation seemed to have
driven the Evil  Spirit away.
  All such are doubtless sane, but on the borderland. 
176               MENTAL DISEASES.

  You  will notice no delusions  exist.  The bent of
mind is simply some dominant  idea leading, impul-
sively,  to  action.   Did  delusions exist and action
taken based on  these  delusions, then would we  have
diseased conditions, weak will-power, and, doubtless
insanity.   Many such are among the criminal classes.
  Dean, in his " Medical Jurisprudence," tells us of a
young man, twenty-one years old, who lost his father
at an early age, and never evinced much love for his.
mother.  When eighteen years of  age he began to shun
society, and felt a strong desire to commit murder.
  Sometimes, when  embracing  his mother, his face
would flush, his eyes  sparkle, and he would cry out:
" Mother, save yourself ; I am forced to kill you." He
kept  his mental equilibrium  by a strong effort of the
will.  Could  we read  humanity in its promptings,
impulses and  inhibitions, we  would  be astonished at
the number of bad acts refrained from.  A dramatic
poem by Rossetti has  the confession of a  murderer,
who killed  his  mistress  because  of  a dominant idea
from  which  there  was  no  release,  except in  the
execution of the deed :—
   " ' Take it,'  I said to her the second  time,
     ' Take it and keep it;' and then came a fire
     That burnt my hand, and then the fire was blood,
     And sea and sky were blood and fire, and all
     The day was one red blindness ;  till it seemed,
     Within the whirling brain's entanglement,
     That she, or I, or all things bled to death.
     And then  I found  her lying at my  feet,
     And knew that I had stabbed her, and saw
     The look she gave me when she took the knife
     Deep in her heart." 
GENERAL BODILY  CONDITIONS.        177
CHAPTER XVIII.
         GENERAL BODILY CONDITIONS.
In treating those with brain disease, it is well to keep
in mind the fact that ab extra abnormal conditions
often occasion insanity, and that the removal of them
means  recovery.  Heart disease, intestinal troubles,
dyspepsia,  anaemia,  hepatic complications, diabetes,
albuminuria, and any state which  will bring about  a
general malaise are  excitants, the result of which is
insanity.
  Uterine and ovarian disturbances and diseases do
not produce insanity to the extent supposed.  This
statement is now supported by some of the best and
most conservative  gynaecologists on this Continent,
such as Skene and Goodell.  It is a matter  of regret
that modern surgery, which has made such advances
during the past  decade, has unsexed so many women
because  of  slight  troubles  in  one or  both ovaries,
under the impression that they are the cause of many
nervous diseases and mental troubles.
   It is safe to say that not over three per cent,  of the
female  insane are afflicted with  serious uterine or
ovarian  disease; yet, a  large percentage  of  those
admitted show evidence of  medical or surgical treat-.
ment along gynaecological lines,
    12 
178
MENTAL DISEASES.
  In some of the United States legislative enactments
are  in  force against  oophorectomy,  except under
stringent regulations.   It is  a matter of regret  that
law is obliged to  step in between a  surgeon and his
patient.
  Uraemic  conditions are  often  present among  the
insane.  Sometimes these are associated with mania,
but more frequently with melancholia.  This mental
depression  is sometimes slight,  but is often so pro-
found as to lead  to suicide.   Uric acid, when in excess
seems to have a demoralizing effect  upon the nerve
centres.   The tendency for self-destruction is greatest
after  wakening  up  in  the morning.    It is possible
that the increased  alkalinity of  the blood at this
period leads to consequent increased solubility of uric
acid, hence the toxic effect  on the mental condition.
  Many cases, with  a sense of ill-being, are classified
as neurasthenics because of brain starvation, who are
simply the victims of slow uraemic poisoning; the nitro-
genous waste products in any form, if unduly retained
in the blood or  abnormally produced, deteriorate the
life current, and the first to feel the inimical influence
is the brain.   The condition  of the blood stands first
as a great causative agent  of insanity.  The order of
sequence often is (a) trophic change, which, through
nerve influence, affect such  excretory organs as the
kidneys; (b) dead tissues  are retarded or changed to
toxic agents,  because of disturbed organic  function
before excretion can take  place;  (c)  as a result, the
most susceptible centres are poisoned. 
GENERAL BODILY CONDITIONS.        179
  In this connection, it may be noted that in melan-
cholia, stuporous insanity and dementia, it is found, as
a rule, that the number of blood corpuscles is sensibly
diminished, more especially among the female insane.
The haemoglobin is less in quantity.  In acute mania
there is litte change in  this respect.  There has  been
found an increase in the specific gravity of the blood,
especially in  epilepsy, melancholia, general paralysis,
and secondary dementia.  There is seen no character-
istic change  in the  relative proportion between red
and white corpuscles.
  The chlorides, phosphates and urea are  often found
in excess, but also below normal.   The  quantity  and
quality are not sufficiently definite  in  each  form of
mental disease to enable us to formulate a clinical  law.
  Among the  pathological products of the  kidneys,
sugar and albumen  are usually found, but  their re-
lation to the varied forms of insanity has not received
that attention which the subject demands.
  There is a wide field open for exploration in ascer-
taining the sympathetic relation which  exists between
the physical  disorders  of all bodily organs  and the
nervous systems, especially the cerebrospinal centres.
This intimacy is very great in the  abdominal viscera,
as wras well known to  the ancients, hence, the names
melancholia, hypochondria and phrenitis.

             Temperature and Pulse.
  After a number of years of close observation of the
heat of the body and the quality of the pulse in many, 
180
MENTAL DISEASES.
 if not the most, of the diseases of the insane, I have been
 convinced  of  the unreliability of  those two tests,  if
 depended upon alone.  When we take into considera-
 tion the difficulty of finding the same heat twice under
 apparently the same pathological conditions, in the
 same patient;  also that scarcely any two thermometers
 indicate  the same degree under exactly similar influ-
 ences of heat or cold, and that alarming conclusions are
 drawn from only a few degrees above or below the
 normal standard, it is evident  that  as a diagnostic
 method it needs to support it collateral confirmation in
 other quarters.  If a number of thermometers are put
 in contact  with the same  axilla or  under the same
 tongue it will be seen how fickle they are, and that no
 two of them agree exactly, even if adjusted as at pres-
 ent constructed.   This untrustworthiness is  also true
 of the pulse, both in respect to its frequency and inten-
 sity.  A  sudden bodily movement, a, passing emotion,
 a transitory excitement, may accelerate  the  pulse, or
 a shock  of  depression may  lower it without there
 being any disease present.
  All that we  can glean from the tone and frequency
 of the pulse must be of a general nature, and  may
indicate  disease,  or  adventitious  circumstances not
abnormal.  Even in disease different persons have no
 uniformity in  this respect, so that its diversity and
changeableness often  put medical men  astray, were
they not  led to just conclusions by other and more
certain researches.
  Many  asylum reports give the temperature  and 
GENERAL BODILY  CONDITIONS.        181
pulse of a large number of patients  afflicted with
dementia, mania, paresis,  latent phthisis, etc., or it
might be of two combined.  Conclusions are  drawn
from these two sources of  information not altogether
warranted from any observations I have made  here.
  To put the matter fairly  to  the  test, I selected a
number of cases belonging  to these classes, and  the
temperature  and  pulse  were  regularly  taken  for
weeks  together,  morning  and evening.   No con-
clusions could be drawn from these of a satisfactory
character except in a general  way ; in dementia  we
found the heat and pulse below the standard of health,
but for several days at a time they would take a leap
upward without any reason for so  doing being dis-
cernible.
  In cases where dementia and  consumption were
combined, both, as a rule,  were  found above normal,
but in  a erratic way they would come down consider-
ably and stay there for a few days at a time.
  The  nearest approach  to stability was  found  in
paresis and consumption combined ;  both were above
normal, and found to be uniformly high.   In paresis
alone the same uncertainty prevailed ;  they rise and
fall without any  regularity, but oftener above normal
than below.
  The  temperature and pulse give general indications
of bodily disturbance  in disease; but, so far  in  our
investigations neither  pulse nor  thermometric tests
show indications of the genus  or species of insanity
or its ally called  latent phthisis. 
182
MENTAL DISEASES.
CHAPTER XIX.
                    AMENTIA.
Amentia, meaning mindless, is an erroneous definition.
All of this class have minds, although of a rudimen-
tary nature.  To be without mind  must, of necessity,
mean the extinction  of  a human being.  Under this
term two classes are usually grouped.
  1st. Idiocy.
  2nd. Imbecility.
  Idiocy may be  defined as a condition in  which is
found circumscribed brain  structure, from want of
development.  This defective growth may be from
birth, or may exist by arrest of  brain expansion dur-
ing the infantile period.
  By virtue of this  deficiency the mind is incapable
of acquiring such experience or mental capacity as
would fit the possessor in any way to fulfil the most
trivial duties of life as a social being.  Some authors,
like Esquirol, make three degrees of idiocy, and others
make two, based upon the scale of intelligence.
  They  are  usually deficient in physique, small and
symmetrical heads, but  sometimes very  large.  The
sensibility  is usually low, and  they  are  subject  to
neuropathic complications, especially chorea, epilepsy 
AMENTIA.
183
and paralysis,  They have no morals, and their lives
are largely  instinctive.   Occasionally  they develop
artistic capacity and aptitudes, which are capable of
little development or cultivation.   Bacon says : " An
idiot is a fool or a madman from his nativity, and one
who has never had any lucid intervals.  Such an one
is described as a person that cannot number twenty,
tell the days of the week,  and does  not know his
father and mother."
  Psychologically, an  idiot is a human  being who,
from defect or disease of the brain, at a period of life
before the mind has  been developed, has suffered an
arrest of mental growth.  The time of attack may be
before or after birth, sometimes so late as four or five
years after,  and thus the  legal definition that idiocy
is  " from nativity," is not strictly correct.
  Idiots of the  lowest type have merely organic life.
In a step  higher the mental condition more nearly
approaches ordinary intelligence.  Such patients have
sensations of heat and  cold,  hunger and  thirst, pain
and a low form of pleasure, as in the brute creation.
All are purely animal in instinct and  lower  than the
higher brute creation in intellect.

                    Imbecility.
  The distinction is only one of degree between the
imbecile and the idiot, although  it is convenient to
give them two designations.
  Like idiocy, imbecility may be  congenital, or may 
184
MENTAL DISEASES.
be arrested development in early childhood.  The de-
fect is less in degree, although of the same kind.
  It is observed in the mental growth of the child by
improvement being more marked in the imbecile than
in the idiot.  It is slower than is that of a merely so-
called " stupid child " in  acquiring new ideas  from
experience.
  Some people differ from others in the  amount of
their mental capacity ; so do imbeciles.
  Some imbeciles approach so closely in intelligence
to the stupid citizen, that it is sometimes  difficult to
say to w7hich class either belongs.
  Some medical and legal writers make a test by the
number of the words such habitually use.   It is not
based on that of cram, but of habitual use in every-
day life.
  Shakespeare used about  fifteen thousand words.
Milton  used eight thousand.  Ordinary,  every-day,
ignorant people seldom used more than four hundred.
  We can  descend the  scale to imbeciles, who  may
use only one or two words, such as no and yes, or pa
and ma.
   When the process of development has  come to a
premature end—that is,  there exists congenital mental
deficiency—then we have what jurists call Dementia
Naturalis.
   We have an ascending scale of intelligence in idiocy,
imbecility  and iveakness  of mind.  In these classes
the process of development has not been carried far
enough.  In insanity the process has been carried far 
AMENTIA.
185
enough, but has, in adult life, diverged  into a wrong
and downward direction.
  In mere weakness of mind there is every degree.
At one end of the scale is the person who is not quite
up to the average ; who is found by  his friends and
acquaintances to be a little dull; who  was in  a  lower
class in school than others of his age;  who, in spite of
assiduous study, got plucked  at  his examinations;
who is slow to appreciate humour; who is incapable
of grasping ideas of a moderate degree of abstractness
or complexity;  who,  if  he reads works  of fiction,
enjoys  only  those which deal with incidents and
adventures.  Such men, if they possess industry and
power of application, often attain a degree of success
in life which surprises those who know the  narrow-
ness of their intelligence.  The  solution is in the fact
that  their interests are so circumscribed  that their
application to the  object they have in view is not apt
to stray.   The attainment of any end  depends more
on the steady,  continuous  application  than on the
scope of mental ability.
   The  line which divides the  dull or weak-minded
man from the imbecile is the ability to earn  a  living
in an intelligent way.
   The  man, who  can  earn  his  living, may be  a dull
man, a stupid man, a man of feeble,  limited  intellect,
but he cannot be called an imbecile.
   These  two classes  are in  striking contrast to a
 thoroughly healthy, vigorous man.   He has not only 
186              MENTAL DISEASES.
those activities  by which he avoids direct  physical
danger, but also defends himself  from it.  He earns
his livelihood with discretion and wisdom.   He rears,
feeds,  clothes  and educates  his offspring.  He does
his share of the duties  required of him as a social
being  and a  useful  citizen  with vigorous  mental
power.
   He has energy to spare to recreate himself—it may
be in  the  pursuit of  literature, art or  some other
hobby.   The weaklings  of  the classes  I have  de-
scribed have no  such  ambitions or desires.  Animal
pleasures or silly inanities or childish notions fill  up
their cup of enjoyment, in which is that  of to-day and
little, if any, care for to-morrow.
   Occasionally a case of imbecility presents itself in
which  one isolated group of faculties is of average or
even more than average development.
   Such as the cases in which persons,  otherwise im-
beciles, show a talent for music or for calculation.  In
such examples the deficiency in brain development is
not uniform.   In some directions the development has
proceeded to a normal  extent, while in the remainder
it has failed.
   The unlettered savage  has average mental capacity
in the chase and  in warfare, but otherwise he has a
child's mind in  a man's body.  The  baubles of the
child please him, such as red cloth,  beads,  looking-
glasses, and such like. 
AMENTIA.
187
  The  gradations of mental growth might  be illus-
trated in this way, omitting the affective nature :
  Arrested
Development.
Normal Growth.
Moral idiot. No ethical feelings.	6th Step.	Moral nature developed.
	5th Step.	Full intellectual development.
	4th Step.	Average man possessed of ab stract and concrete ideas.
Circumscribed mental scope and arrest.	3rd Step.	Higher mental capacity.
Imbecility.	2nd Step.	Dawning intelligence above in stinct.
Idiocy.	1st Step.	Animal instincts only.
	Birth.	
 
188
MENTAL DISEASES.
                CHAPTER  XX.


                  MIND STRESS.
The civil engineer will  give  the  weight necessary to
break down a beam of wood,  iron or steel, if the size
and kind of each is given.  In other words, he knows
from experience the resisting power of  various ma-
terials.  It is a somewhat analogous law which exists
in respect to the capacity of the brain to preserve its
integrity against all kinds of physical  and  mental
strain.  These  powers on the one hand and the brain
tension on the other could  be absolutely  formulated
as in mechanics, were all the conditions as well known.
These varied forms of stress may come in the form of
physical  disease of  the brain itself; from  indirect
bodily disease  in  distant parts, or through  mental
trouble such as worry, fear, emotional shock  or any
form  of  mental excitement and  consequent  exhaus-
tion.  Each brain, in respect to resistance, is a law
unto itself, but it  is subservient to this general con-
dition.  One may  be robust  and full of  vigor, hard
to tire and  soon rested.  Another may be feeble and
languid, with  the recuperative energies  slow.  The
former might have, in an analogous way, the vitality
and  strength of the  oak or  the  elasticity and dura- 
MIND  STRESS.
189
bility of steel; and  the  latter only the weak fibre of
the bass-wood or the pliability of iron.
  The organ of the mind, when healthy and natur-
ally strong, is capable of a  large amount of steady
work, but each person must  gauge  the tension  upon
his own  brain  by  the  effect  produced daily in its
working.  It will soon throw out signals  of distress
when overstrained.   In  this  age of tireless and sleep-
less energy, with sharp  competition in all the  walks
of  life, many  a man  is like the engineer who  is
running a twenty horse-power steam engine at twenty-
five or thirty horse-power.   The tear and wear will
be tenfold that which would take place from normal
work, just  as running a mile expends more energy
than would walking five miles.
   In  the young  and vigorous the unusual demand
may  not always immediately show malign results;
but as the years go by, and the vital powers have
reached the  maximum of activity, or it may be, by
lapse  of time they are on the decay, then nature has
its revenges, because of the violation of its laws in
early life, as it never shows  pity to the transgressor.
   Early or late the warning comes in one of many
ways : It may be by want  of sleep, by a feeling of
fatigue when little  or  no work is done, by mental
lassitude and incapacity, by  a fee ling  of goneness in
the body and a  lack of power of concentration of
thought,  by  waning memory, lowness of spirits and
defective appetite. 
190
MENTAL DISEASES.
   In  short, body and  mind  are  at  the ebb, and are
going downwards and  outwards " beyond the bar."
   Nature has its penalties inflicted for violations of
law, often long after the infraction.  The fast young
man  begins  to know  this in middle  life, when the
executioner has overtaken him.  The brilliant student
may so eat up  his vital reserves in  college spurting
as to  shackle his  mental vigour in after life.  The
business man, immersed in mental strain  beyond his
calibre, may see no loss of vital  elasticity for years ;
but the day is  sure to come  in many such, when the
warning cry is too late.  A man finds, to his consterna-
tion, that in middle  life his  energy  is flagging.  He
puts on an extra effort to make up for mental weari-
ness, and  thereby intensities  the  evil.   In his  sleep-
lessness  he hears  the  clock  strike  all  the  hours
throughout the darkness of a seemingly endless night-
He rises in the morning unrefreshed, and possibly
with  a tinge of low-spiritedness.   The  appetite is
impaired,  and an otherwise equable temperament has
become irritable, and brooks  little opposition.   Busi-
ness, in which he formerly took a delight, has become
a bore.  By noon mental exhaustion  sets in, as the
brain  has  not procured  its usual rest, nor the great
nerve-centres their  well-digested pabulum.  He was
a social man, but now he has  no zest  for the company
of relatives, friends  or companions  as  he once had,
and he is himself   annoyed  at  his  hermit  desires.
Intense introspection takes place, and  even ordinary
feelings of  body are  magnified  into monsters  of 
MIND  STRESS.
191
disease.  His mind is centred on self; and, try as he
may to divert his attention objectively, the pendulum
of thought will  swing back to the morbid point with
aggravating  persistency.  He  feels  and  struggles
against this pelting from the first drops  of the  com-
ing mental storm, and  often  successfully, but if this
condition intensifies, then is the  borderland of insan-
ity reached.  Delusions usually set  in, and although
the patient knows them to be  such, yet they may
dominate his actions to some extent.  A good business
man avoids Victoria Street, because  he has  the idea
that some  calamity may happen to him on it.  He
knows the morbid fear  is absurd ; nevertheless, to
quiet the perturbed feeling, he avoids the street.  An
intelligent  professional  man, actively engaged in his
daily work, cannot sleep in a detached house, because
he has the  notion that it may blow  down in  the first
gale.  He  feels  secure  in a  tenement house, and, at
the same time, laughs at the absurdity of his fears.
  A commercial traveller dreads to ride  upon a  well-
built and well-equipped branch line of  railroad, and
is in a nervous condition of alarm when he is  com-
pelled to travel on it.  He has often gone many miles
round to avoid it.  He states he can give no reason
for the possession of  this unreasonable fancy, yet, it
has remained with him  for years.   A woman who is
fond  of shopping indulges in it  as a recreation, but
never goes  into one large store in this city, where she
could feed  her  propensity to  the  utmost,  because
she has a fear of the ceiling  falling down  about her 
192
MENTAL DISEASES.
ears.   The heavy pillars  of  support and the solidity
of structure have  no influence on this dread.   Scores
of analogous cases might be cited; but, in all is found
a  substratal  condition of nerve  starvation, accom-
panied by a general sense of ill-being.  Strange to
say, the absurdity of  the  delusions is  seen, yet they
dominate  and control individual  action.  Such men
often struggle  on for years  in this  unsatisfactory
condition, if  insanity  should  not  intervene,  until
middle life is reached;  and  at this  trial epoch for
men, as well  as  for women, we often  see  premature
old age set in  as  the first step of senile  decadence.
" The pith and  moment"  of  vigorous manhood are
waning.   The capacity for entering into new  enter-
prises  with the  vim, judgment  and discretion  of
earlier years  is  very much weakened.   In short, the
grip of mental  life  is being loosened  prematurely
because of undue mental strain throughout a previous
period of  abnormal energy, and, it may be, of excep-
tional  trial.
  It  is often  the  case—especially  in   commercial
circles, in industrial  centres and  in  professional
routine work—that, as life  advances, the demands
upon  time and  upon mind  increase   rather  than
diminish.   The  work enlarges and  becomes more
complicated;  and, as a result,  the busy man—who
looked forward at, say, fifty-five years of  age, to retire
with a competency—may have the riches he coveted,
but has not the opportunity nor even the desire to
seek quietude and  rest.  We too often forget that the 
MIND STRESS.
193
life-work of a citizen becomes, by repetition, to him a
second nature,  and,  therefore, he has no  enjoyment
but in doing that work until his sun has set, or at
least until  the gradual decay of old age has made
him lose his former interest in mundane things.   As
someone has well said :  " He may have something to
fall back upon, but nothing to fall back to."
  Of course, there are exceptions to this  law of  life.
Many brains of fine  and tough structure luxuriate in
great activity.  To such labour is life, and the tireless
capacity of  such exceptions is often astonishing ; but
the masses  of  ordinary men  are not thus endowed.
As a rule, the educated  brain has more endurance and
more  rebound  to it, like a steel spring, than  has that
of the  ignorant.   By  the  educated is  meant not
simply the  college-stuffed  brain, but any  organ of
thought which  has been trained  in the school of ex-
perience, and has  been  the  recipient of knowledge
and wisdom from all sources of information.
  The higher organization has in it greater recupera-
tion than has the  less complex  nerve centre, just as
have the skilled rower's or  pugilist's arms, by training
the muscles of the body, more power  than have those
of the clerk or cleric, who needs no  great muscular
development in his daily work.   It is also true that
unless  these athletes are  overtrained, their muscles
will recover from injury and disease more readily than
those of their more flabby fellow-citizens.
  This law of  repair is  also seen  in the percentage of
recoveries among the insane, wise and ignorant.  It
    13 
194
MENTAL DISEASES.
is true there is  little insanity among savages,  but
the reason of this exception is  obvious.  The mental
strain is little,  and the indolence of such, especially
in the tropics, leads rather to mental inertia than to
morbid exaltation.  Their happy-go-lucky mode of
life is in striking contrast to  that  of  the seething,
struggling masses of Christendom.
   It is easy to propose a remedy.   We say to such,
" Take life easy.  Do not  worry.   Be content."  The
answer is: " We cannot.   On the farm, at  the coun-
ter, in the shop, in the professions, on sea and  on
land we must push our varied interests to the utmost
or we  will  come to ruin."  Keen  competition, low
prices  for  work  and  its products, the  additional
demands of a social kind or of  a  public kind which
have come in with our civilization, all compel toil of
brain or hand, or  both, from  which  there  is little
cessation until life  closes or, it may  be, reason is
dethroned.
   This indictment against themselves is true ; and, as
a rule,  myriads  of such perish mentally, and, what is
even worse,  before  the eclipse  comes add  in their
children to the great army  of defectives, who now
swarm in every land and  in  every clime.   Even  the
mentally great  of the  earth  have  seldom  equally
famous  descendants,  because genius burns  out  the
superabundant energy, and consequently has no such
bequeathment as  a legacy to descendants.   Here is
where  heredity shows its baneful effects,  and which
are working untold woe in all communities. 
MIND  STRESS.
195
  Health Boards chase  the  microbe to his lair and
seek his destruction.  They charge the plumber with
culpable homicide because of his bad work.  They
wage war against filth  and foul  air.  They throttle
endemics and epidemics, and face the various scourges
which march by sea and land with germicides, anti-
septics, fire and  water.   It  is  well,  but  the  more
insidious mental  diseases  which  produce  a  most
deplorable condition in  the  tens of thousands of our
fellow-beings,  to which death itself is  a relief, are
never thought of, except by a few, and these are only
voices crying in the wilderness.  Prevention is better
than cure, yet at present we are, so to speak, picking
up  human  fragments at  the  bottom  of a precipice,
but  have no  danger signals at the  brink.   Health
Primers  on the  baneful  effects of  secret vices;  on
heredity;  on  unsuitable marriages  from a  health
point of view;  on the active and predisposing causes
of insanity ; on the evil effects of  mental strain, and
such like, would be of invaluable  benefit to the com-
munity.  Many of these human ills are preventable,
but about  the  consequences, of which so many are
ignorant, because of a  silly  sentimentality  among
those who are qualified  to instruct, little is known by
the people.
  There is  a natural desire  in those thus  afflicted to
seek relief.  Unfortunately, many such find it, tem-
porarily,  in the use of some form of spirituous liquors.
The fleeting paralysis  of  body  and  mind  induced
thereby gives comfort for the time; but the effect has 
196
MENTAL DISEASES.
to be kept up, else more profound  trouble than ever
supervenes.   The end  is often  a  state  of chronic
alcoholism and  final  collapse.  Some seek relief from
this  thraldom of  mind-pain by the use of  opium,
morphia, chloral or some  other such seductive drug.
The  constant use of  such  drugs  ends  in mental
enfeeblement or  insanity, and  in  such  wrecks  of
humanity is seen the most deplorable  affliction of a
living  death.  It is  forgotten that, in the struggle
through life, nature is ever fighting towards recovery
in disease or under any untoward circumstances.   As
a condition towards health, it is handicapped by any-
thing which lowers the vitality or prevents recupera-
tion.  This is especially true when stupifying drugs
are  used  to produce  so-called   sleep  in insomnia.
Natural sleep is replaced by stupor.  The appetite is
interfered  with;  hence,  insufficient  food.   Good
digestion is followed by dyspepsia, mal-assimilation
of food,  mal-nutrition and  the  nervous debility  in-
tensified.   Under   such   drug   influence  remedial
measures are impotent.   Wholesome food, cleanliness,
good air, exercise and short hours of mental work are
" Love's Labour Lost," yet they are our sheet-anchor in
all such cases.
   At this stage the cure-alls are  eagerly sought after.
Drowning  men  catch  at  straws.  The  seductive
pamphlet, full  of testimonials  of  wonderful  cures;
the  flaming falsehoods in the secular  and religious
press, which  promise almost to  raise  the dead; the
wonderful  golden promises  to  cure evil habits  by 
MIND STRESS.                19?
i   injections of  paralyzing nostrums into the body ;  the
   insane teachings that disease is only a mental fantasy;
   the equally nonsensical  belief that  faith alone can
   cure all human ailments, but  cannot set a broken leg
   nor restore to their  right minds  the insane, the most
   pitiful of  all  God's  creatures, nor lessen by one  the
   inmates of the Home  for the Incurables—have their
   day.  All  such  promises look  so  plausible, when
   backed  up  by  designing rogues   or  self-deluded
   believers,  and look so feasible to those  whose mind-
   stess is hard to bear, and who may find no immediate
   remedy from  their  physicians ; hence the rich field
   for quackery and its many allies.   Credulity cannot
   be  eradicated from  the  minds of men  as long as a
   belief in all human  testimony exists.  The distress is
   present, and  the possibility of immediate cure is  so
   seductive, when accentuated by  so  many who affirm
   that such-and-such  mixtures, extracts,  pills or lini-
   ments have  done  wonders  in similar  cases.   The
   fundamental  law of  our nature  is forgotten, namely,
   that all humanity can do with its  best remedies is
   simply to  stimulate  the master-builder  into  activity,
   to repair the waste places and to furnish  him  with the
   suitable material to build up the body  or to carry
   away the  dead tissues by the  excretories. 
198              MENTAL DISEASES.
CHAPTER XXL
  NOTES ON THE CONDITION OF PATIENTS ON
                 EXAMINATION.
A. Bodily Condition.—Such as weight, temperament,
muscularity, fatness or leanness;  expression of face
and  general appearance;   any  bodily  injuries,  or
wounds or scars of past hurts.
  B. Organic Functions.—As to digestion, condition of
bowels, appetite.
  Condition of  the skin, as to eruptions, moisture and
abnormalities.
  The  circulation, as  to pulse,  cardiac sounds, and
injection of the conjunctiva.
  The  condition of  the  respiratory apparatus, as to
the state of the lungs,  breathing, and rapidity of the
respiration.
  The  state of the glandular system, as shown  in the
examination of the  urine,  state of liver, spleen and
thyroid.
  C. Sexual Functions.—Especially as  to habit, mas-
turbation, and past or existing syphilitic attacks.
  In women, enquiry as  to  catamenia,  discharges,
pregnancy, syphilis, and the trial epochs of life.
  Enquiry as to previous attacks of such diseases as
rheumatism, fever, inflammation and gout. 
EXAMINATION  OF PATIENTS.         19JJ
  D. Nervous System.—Enquiry as to the existence—
present or past—of paralysis, epilepsy, hysteria, hypo-
chondria and neurasthenia.   Any diseased conditions
along the line of nervous disturbance are to be care-
fully noted.
  The special senses need attention, especially as to
illusions and  hallucinations of sight, hearing, smell
and taste.
  The touch and nervous sensibility often give valu-
able information  in our diagnosis.  Sense  of pain,
reflex action, anaesthesia and hypersesthesia, are to be
thoroughly enquired into, as well as the various re-
flexes.
  Heredity is never to be forgotten in its tendencies
and reproductions.
  E.  The mental symptoms not directly related to the
special senses.—In this class we are to seek for psychic
conditions only.  These would include consciousness,
identity, power of attention, memory for recent events
and  for  past events,  coherence of language, mental
exaltation, mental deprivation, depression of spirits,
sleep  or insomnia, delusions, propensities, habits  and
bias;  such as  using obscene  language, dangerous
to others, maniacal  excitement  in its various forms,
indecent conduct, suicidal and destructive tendencies,
or mere negation of normal  mental activity, as in de-
mentia.
  The following tables are used  by me not only to
note the post-mortem conditions, but also to record as
far as possible  the insane life history of the individual: 
RECORD  OF  AUTOPSIES IN  THE  HOSPITAL  FOR THE  INSANE,  TORONTO.
GROSS LESIONS.
No.
NAME.
CAUSE OF
 DEATH.
Scalp, Skull
   and
Membranes.
 BRAIN.
Si>.f;r., Wcic
  Uld Size,
  BLOOD
 VESSELS
OF BRAIN.
SPINAL
CORD.
 BLOOD
VESSELS
OF BODY.
REMARKS.
MICUOSCOPK.
CAUSE OF
 DEATH.
Scalp, Skull
   and
Mkmkkankh.
 BRAIN.
Kp.s,a.,\Vci,
 BLOOD
VESSELS.
SPINAL
CORD.
 BLOOD
VESSELS. 
No.
GROSS LESIONS AFFECTING OTHER ORGANS OF  THE BODY.
Lungs.  Heart. Stomach.1 Liver.
Spleen. Kidnbys.
Intestines. Bladder. Uteris
REMARKS.
OTHER  PHYSICAL  CHANGES  NOT  NORMAL  IN  CHARACTER.


                      THE SPECIAL SENSES, j      SENSATION.
MENTAL  CONDITION.—ACUTE
CHRONIC
Circular    Insanity of
Insanity.  Moral Nature.
  Hallucinations,
Illu sions, Delusions.
REMARKS. 
202
Mental diseases.
CHAPTEE  XXII.
    TREATMENT OF THE VARIOUS FORMS OF
                   INSANITY.
In  administering drugs to the insane it is  to be
remembered that the mentally diseased  will  often
not express their feeling nor  give  a true statement
of their aches and pains as the sane  do.  We must, to
a great extent,  judge of their  condition by  what
knowledge our  experience and senses give us.  A
maniacal, melancholy  or demented patient may have
retention  of urine, loaded bowels, hernia, bleeding of
the bowels or any one of numerous  complaints and it
may be of such an obscure  nature as may escape the
vigilance  of the physician and attendant  until such
assumes a serious aspect.
  It should also  be accepted as a truism that medicine
is only an assistant  to nature.  The vital  powers of
the physical system in its efforts to preserve live and
restore  health are the curative resources given  to us
in every form  of disease.  In the first place, then, we
are not to frustrate  these by undue intermeddling;
and, in the second place, we are not  to expect medi-
cines to take  their place.  There are no cure-alls in
pharmacy and therapeutics.  We give stimulants, we 
treatment of insanity.
203
brace up with tonics, we quiet with sedatives, and we
lull pain and give sleep with anodynes and narcotics,
but, in all  these  efforts we only endeavour to guide
nature to health.   We cannot originate any powers it
does not possess.   We  can only steer the vessel, but
its  propelling power  must be  left to  nature's vital
agency.  Insanity, like many other forms  of disease,
will often  run its course  in  spite of all remedies.
Our aim must be to  provide  pabulum, and sustain
nature in  its struggle  against  the retrograde  steps
towards dissolution and death.
  One of  the first considerations  in treating the
insane is sanitary surroundings.  These are more apt
to be neglected among the insane than  among the
sane at their homes.  If they are violent or suicidal
the windows are apt to be fastened down and shutters
put up ; the doors of their  rooms  are  kept  shut;
the fresh air and sunlight are excluded; a vitiated
atmosphere is  kept in.  Personal cleanliness  is too
often neglected from ignorance  of what attention in
this respect is necessary, or from fear of unduly excit-
ing the patient.   Food is not given regularly, and the
kind  may  be mere slops or abominable  nick-nacks,
instead of  nourishing nitrogenous food, such as milk,
eggs, fresh  meat and fresh fowl.  There is more fibre-
building material in a  good beefsteak than in a hogs-
head  of  so-called  beef-tea with the beef fibre left out
of the decoction.
  In nursing the  insane, the necessary combination of
firmness and kindness  is  not  often  found in private 
204             mental  diseases.
houses,  yet  how indispensible are all these  simple
requirements to induce health, not to speak of  mental
recovery.
  Again, medicine is left by a physician to administer
at stated  times.  It may  be a  necessary  sedative,
stimulant or tonic.   His  back is no  sooner  turned
than some local  wiseacre throws doubt on the wis-
dom of  the doctor, or on the  efficacy of his remedies,
or on the  necessity of  his dietetic and  sanitary rules.
They are ignored, and yet he is held responsible.
  Herein comes the advantage of asylum treatment,
where  no such untoward circumstances exist.  All
the conditions, except  hospitalism, are favourable to
recovery.    These drawbacks are especially true of
the pauper insane who are kept at home, and where,
of necessity, the attendance and  nursing must be of
the most crude kind.
  Our diagnosis is  often hampered, because of those
who are full of delusions and imagine they  have a
disease  of some kind,  which  has no existence.  It is
useless to reason the matter with such, and the only
other alternative is  to give a placebo of  some kind, and
in this way employ mental therapeutics and  watch
developments.   In these  three  aspects—of (a)  not
noticing their ailments, (6) hiding  real troubles, (c)
having  the   mind  filled  with imaginary ones—we
labour under disadvantages  which  do not exist in
treating the sane, if not delirious.
  Nor are these all our difficulties.   When medicines
are given to a sane person, on a  second visit we are 
TREATMENT OF  INSANITY.
205
greatly guided in our future treatment by the account
an intelligent and non-delirious patient will give us
of the effects of our previous administration.
  There may be idiosyncrasies against certain drugs,
of which we were not aware.  The medicine may not
have the desired effect  on account of causes which
may be obscure, but which the patient may be able
to assist in solving.   A large number of the intelligent
insane can be depended  upon in describing symptoms,
and on the other hand  many cannot  be relied upon
in making our  diagnosis, hence the physician labours
under a disadvantage.
  Under these  circumstances we must fall back upon
our experience  of the therapeutic value of different
drugs as usually administered, until we are convinced
of their injurious effects, their negative  character, or
beneficial  results.
  It is possible that asylum medical officers  cannot
do much better for the  insane than can an intelligent
outside practitioner; but in asylums all the conditions
enumerated are imperative, and no outside interfer-
ence is allowed.  As a rule, the  hospitals for the
insane in christian countries adopt  the most modern
methods and endeavour to bring about the  best con-
ditions necessary to  recovery.   It  is  true that there
are a few neurologists  in some countries not  far off,
who sneer at that band of excellent  and, in a majority
of cases, able men who  make their life work the care
of the insane, because they do not devote more time
to the study of  neurology and kindred subjects. Now, 
206
MENTAL DISEASES.
as a matter of fact, the most advanced students along
this line of thought in  Christendom  to-day are not
these critical  theorists without  practical experience,
but the men who are daily among the insane and live
in a clinical atmosphere.
  Synthetical chemistry is furnishing a large variety
of sedatives and narcotics such as sulphonal, phena-
cetine, chloralamide, trional and such like. While not
coming up to all their advocates claim for them;  yet,
there is no doubt, their calmative effect in mild mania
and in  the restlessness of melancholia makes them
valuable additions to our therapeutic agents.  At the
same time, it is not well to accept as gospel  truth all
that is said  of the hundred-and-one chemical  sub-
stances which  are being produced  with wonderful
rapidity in the myriad laboratories of to-day.  New
remedies—so-called—are being thrust upon the medi-
cal profession;  so are old  remedies, brought into use
under new methods of manufacture and of  chemical
union.   They are produced in many forms simply to
sell, and in the purchase of many of them the profession
is "sold."   They serve their little day and  pass into
forgetful ness, usually with profit to the manufacturer,
and are followed by the exhibition of new substances,
which  pass through the  like evanescent stages of
temporary popularity, largely because of the lauda-
tions of some susceptible members of  our profession.
It is true, valuable remedies may be and are discovered
by chemists and by physicians fond of experiments,
yet it is well to be largely conservative in our opinions 
TREATMENT OF INSANITY.           207
of the efficacy of all new-fangled drugs which may
be thrust upon the market.

                Puerperal  Mania.
  In the treatment of puerperal mania, the following
points may  be  remembered:  (a)  Absolute rest, if
possible ; (6)  the employment of a  competent  nurse,
and, with few exceptions, the absence of such rela-
tives who may have  neither discretion nor judgment;
(c)  child weaning without fail;  (d) bowels  freely
relieved by enema; (e) general  antiseptic  measures
adopted  immediately  before  and   after   delivery;
(/) seeing that the breasts are attended to, being of
paramount importance ; (g) lochial discharges removed,
thoroughly saturate the  womb  and  passages with
quinine held in suspension in tepid, distilled or  boiled
water.
  Condy's  fluid is excellent, as it contains a large
quantity of permanganate of  potash.
  I have found a diffusible stimulant  have  excellent
results, and  such  a  drug in  this condition  of the
patient is calmative in its effects; just as I have seen
in dozens of  cases in ordinary mania the administra-
tion of whiskey in  hot  water, with a warm bath,
quiet  more satisfactorily than many of the  standard
sedatives and soporifics.
  A majority of such cases soon subside, and recover
in  twro or three  weeks.   This statement  refers to
simple puerperal mania of the sympathetic form, and
not to the septic class,  The  outlook  of the latter is 
208
MENTAL DISFASES.
varied, and uncertain as to duration and recovery.
Quinine is our sheet-anchor where  poison  exists.  It
is antagonistic to all forms of  micro-organisms and
to  putrefaction.  Our forefathers  knew this practi-
cally when they put great faith in Peruvian bark and
charcoal as poultices where pus existed.
  Hypnotics may require to be given as a final resort
to allay maniacal excitement and consequent exhaus-
tion, as a continuance of it, without cessation, means
death.   Chloral, or  sulphonal, or paraldyhide may be
used.   A  suppository of  camphor and  chloral per
rectum not  only is  a good general sedative, but no
doubt it allays local excitation.   It is well  to  avoid
hyoscyamus or  any of  the products therefrom, as  it
is a heart depressor, and as it  dries  the  tongue and
fauces  it  might cause   a  distaste for  food.   The
bromides should be  avoided.
  Any of  such drugs should  only be  temporary
expedients, to tide the patient over the critical period
of mental and physical  prostration.  Stop their use
as soon as possible.
  Should the patient recover from the blood poison-
ing, and not immediately rally, the usual  result is a
period of  mental weakness with or without stupor.
Sometimes a mild mania may supervene.   We have
in the  latter class patients hard to manage, as they
are  very  often erotic,  obscene,  filthy  and  often
destructive.
  A large number,  however, of even this class recover
inside  of a year, but quite a few lapse  into chronic 
              TREATMENT OF  INSANITY.           209

and hopeless insanity, especially should there exist a
hereditary tendency.
   On the whole, the prognosis is good, and we are
encouraged to persevere in  our treatment.   Our  aim
should be, among other aids to recovery, to ensure the
feeding of nourishing food, fresh air, cleanliness  and
tonics.  When the acute  stage has passed away, we
trust to the simple forms of iron in effervescent com-
bine,  or in the pyrophosphate of  iron, cod  liver oil,
with one  or  other of the phosphites, or, better still,
the phosphides, peptonized  milk  with eggs, soups of
a substantial kind, and a fair amount of some form
of  stimulant.  I prefer any  of  the  malt liquors to
wine  or any distilled  spirits, in such cases.   Treat
such patients at home, if possible ;  but it must not be
forgotten that home  treatment  too  often means, of
necessity, because  of the  situation,  too much  nar-
cotism and  too little of good  nursing  and general
treatment; too little building up,  and consequent
depression ; too much confinement, especially in towns
and cities, and too  little open-air exercise.   These
unfavourable conditions are often  rendered  more so
by relatives exhibiting too much interference and too
little tact.  Because  of these and  other hindrances,
especially among the poor, the medical attendant  has
his best endeavours very much neutralized,
14 
210
MENTAL DISEASES.
CHAPTEE  XXIII.
           TREATMENT  OF MANIA.
In former times mania was thought to  be caused by
meningitis, and as a  consequence, this supposed in-
flammatory  condition was  treated  by the orthodox
purging, bleeding and salivating.  Occasionally, for a
change, large doses of tartar  emetic were given, the
object being to lower  the pulse, and consequently the
circulation.  Blisters were  applied to the neck, and
many years ago the actual cautery on the nape of the
neck was used in this province.  This treatment was
in accordance with the approved practice of  those
days.   These  heroic  remedies and   methods  are
unknown in our day.   The levelling down has been
followed by the levelling up.  In most cases of  acute
mania we have to consider  what is best to be  done to
reduce the excitement and quiet the patient.   Shall
we  give sedatives or narcotics, or neither ?   If we
give neither, then one  of  three results will  follow :
that is, recovery after a time, if the natural strength
should hold  out, or  a drifting into  some  form of
chronic insanity,  or  death   from  sheer physical
exhaustion.   We  are  well aware  that  if  we can
husband  the physical resources until the crisis  is 
TREATMENT  OF MANIA.
211
over-past, we have gained a good deal; but we know
that in mania it is not drugs alone that will do this.
All  the  conditions conducive  to  health need to be
present, especially good food, well  cooked and plenty
of  it, cleanliness, and  fresh  air.   In  all forms of
insanity this practice should be the golden rule.  Let
it  be  repeated  with  emphasis  that hygiene  and
dietetics must  always stand supreme  in  disease ; if
not, then our  medicines  will  be  of  very secondary
importance, and will not  have fair play.  Were  I
obliged to give up one of these  two classes  of curative
agents in sickness of any kind, then would I let the
medicines go, so important do I consider the former.
The doctrine of " the gospel  of fatness" is a well-
tried dogmatism. These views being  conceded, and
seeing that sleep is absolutely needed in acute mania,
we must consider what is the best drug to  administer.
   If there  be  great irritability  and  persistent in-
somnia, and  no  evidence of permanent lesion of the
brain, then  some preparation  of opium seems to do
best in our experience, either  hypodermically, by the
mouth or per rectum.  It is preferred in the natural
state, but if  any of the salts are used, then  atropine,
in the proportion of the twentieth part to  one part of
the salt, is a good combination, as the one  seems to
modify  the  action  of  the  other.  Sometimes  the
deodorized  tincture  of  opium added  to  bromide of
potassium or sodium produces  excellent results.
   It is well if  we find a state  of hyperemia existing
not to give opium nor its salts.   If  we find the eyes 
212
MENTAL DISEASES.
 injected, turgesence  of  the  superficial vessels of the
* head and neck, a hot head, a pulse neither full nor
 strong, then, as a rule, it  is better not to give opium.
    Notwithstanding what has been said to the contrary
 as regards the effect of opium to produce  congestion
 of the brain, my experience has been that such is the
 case, and if given when contra-indicated, it would
 diminish the chances of recovery.   We are threatened
 with exhaustion and death of our patient unless rest,
 artificial  or  natural, is procured.   Even temporary
 relief may tilt the natural forces in the direction of
 recovery.  The fire  of acute  mania  will  burn out
 after a time, if we can only in the meantime keep up
 the strength with  food, and quiet the nervous system.
 The waste of tissue and of nervous  energy are great,
 so these  must be provided  for by every  means at our
 disposal, but medicine alone is neither meat nor drink.
    If opium  is indicated, then give full doses from the
 beginning, which  in mania, as in  delirium tremens,
 must be  from a half more to twice  the ordinary dose
 if a decided effect is expected.  Repeat every  four
 hours until  three doses are given.  If no effect is
 produced do not continue the opium or any of its salts,
 for  more may  produce a  sudden  cessation of the
 mania and a  dead  patient.  This  is  also  true  of
 hydrate  chloral and other remedies of the same class.  ,
 The exhaustion of the disease, and  the sedative  effect
 of the drug combined, often repeated, may  produce
 fatal results.  The pathological condition may be too
 profound for the remedy to reach and effect. 
TREATMENT OF  MANIA.
213
  Some patients tolerate opium to an enormous extent,
and others find it a very bane to them.   Idiosyncracies
are not to be lost  sight of, because death from opium
may take place ivithout coma in  a  condition which
seems  to  be a combination of asthenia and asphyxia.
Sudden collapse takes  place,  followed by  a failing
pulse, shortness of breath and death.  When indicated,
where  there is sleeplessness and mania, any one of
the following  prescriptions  may be  used with  good
effect:
laa  fjj.—M.
    R   Chloral Hydrate...............   5 ij.
         Sodii. Brom...................   3j-
         Morphise Sulph.................   gr. f.
         Syr. Zingiber........., .
         Aqute  Dist.............
  Dose :  A tablespoonful at bedtime, to be repeated in an
hour, if necessary ;  or
    li   Sodii.  Bromid..................   ^ij.
         Chloral Hydrate..............   giss.
         Tine. Opium Deodor............   3,j-
         Syr. Aurantii.......~j
         AquajDist.........f ™  <lS-ad  3VJ—M"
  Dose :  One tablespoonful at a time.   This may produce
the desired result as a sedative rather than as a narcotic.
  When indicated,  the  following prescriptions  are
satisfactory to  use in any form of mania:
    R   Chloral Hydrate...............   5SS-
         Tine. Hyoscyami fid.............   3ij-
         Aquae........................   3j.—M.
  Dose :  To be given at bedtime. 
214
MENTAL DISEASES.
  Dialyzed  opium  (the same strength as tincture of
opium)  is a good  form to use.   The same is true of
the bimeconate of morphia.
  Neither of these  has the unpleasant after effects of
opium in other forms.
  If a small quantity of one of the  ethers be added,
costiveness  and nausea  will  be  neutralized, and on
some systems this mixture acts as a laxative.
  When resistance  is made to taking these medicines
by  the  mouth, a suppository of  them can be given
per  rectum.  One-third additional quantity should
be given.
  The monobromide of camphor often does  well to
allay excitement of any  kind.  "Four-grain  capsules
every hour will generally have the desired effect after
the second or third dose is given, but sometimes one
dose is enough to quiet, if  not to  cause sleep.
  In mania  a good  sedative or narcotic mixture is as
follows:
     R  Hyoscine Hydro. Brom..........   gr. -1,)
        Chloral Hydrate...............   ►) j.
        Sodii. Brom...................   3j-
        Morph. Sulph..................   gr.  |.
        Syr. Zingiber ..............^ __   ,._.   ,,
         J     &                    laa   f,3j.—M.
        Aqua? ...   .................J
  Dose :  One tablespoonful  at bedtime.   It   is to be
repeated every  two  hours until the patient  is  asleep, or
until three doses are  given.
  To produce quietness in the daytime the following
pill is good: 
TREATMENT OF MANIA.           215
    R   Zinci Yalerianat...............   3j-
        Ex. Belladonna?................   gr. ij.—M.
  Make into xxx pills.
  Dose : One every two hours.
  If the tincture  of Hyoscyamus is  used it must be
given in large doses in mania.   It has often failed to
produce quieting results because we have been afraid to
give it in sufficient quantity to produce desired effects.
From  two drachms to half an ounce  of  the  tinc-
ture has been given by me with good results.  When
exhaustion has set in and collapse is threatened, it is
well to combine it with compound spirits of ammonia
or with the same  quantity of sulphuric ethert  Three
drachms  of it  is equal  to  thirty grains of hydrate
chloral, and  equal to about forty minims of laud-
anum.  It is  simply  a good  sleep  producer when
indicated.  The  well-known remedy  named " Brom-
idia" is composed of  extract  of hyoscyamus, chloral
hydrate,  bromide of potassium and extract of  can-
nabis indica in solution.  Many use this prescription
in acute mania and praise its virtues.
   In a number  of cases of  acute  mania, the fluid
extract of ergot  seemed  to have a beneficial effect.
No doubt this  is because the pathological lesions are
primarily in a state of great cerebral and  spinal hyper-
gemia.  This congestion is  no  doubt  due to a  vaso-
motor paresis.   This  remedy  has  the   well-known
effect  of reducing the calibre  of the arterial system,
and is antagonistic to congestions.  A  fluid drachm
is  given  every  four  hours  for about  twenty-four 
216
MENTAL DISEASES.
hours.   This can then be intermitted with some such
medicine as about thirty grains of bromide of potash
and the hydrobromate of hyoscine, say l-100th of a
grain every four hours until  the sedative  effect is
produced.  Hyoscyamine in the chrystaline form, has
been  used largely by us hypodermically, mixed  in
glycerine, to which is added a few minims of carbolic
acid to the  ounce of  solution,  in order  to keep it
fresh  and  ready  for  use.  Lest  there  might  be
idiosyncrasies against its use,  give  at first only the
l-16th of a grain.   Its influence extends for about
eight hours.  We find,  however,  it is soon tolerated
by the patient, and that after a few  doses have been
given, they must be increased very much to produce
the same  effect. We have sometimes given one-half of
a grain at a time  hypodermically after a few  doses
were taken, with no untoward results, and no  more
soporific impressions than were evident in the smaller
doses previously given.  It  is often tolerated  when
opium or  any one of its salts, or hydrate chloral cannot
be given  with  safety.  Hyoscyamine is prompt and
certain in its action.  It is  non-irritable  as  a hypo-
dermic injection.  It is a good hynotic and a depresso-
motor,  or an  excitant to the psycho-motor centres,
according to the dose employed.  It  often tranquilizes
and shortens  the duration of  mania.   It does  not
affect nutrition if  only given  daily in a full dose at
night.  Hyoscine  is often  used now  instead,  but
caution is needed  as to dosage, as  it is much more
powerful than is the hyoscyamine. 
TREATMENT  OF MANIA.
217
  Conium, in  one or other of its forms, has been
highly recommended in mania.   It  has  been tried
here,  and that somewhat  extensively, a  number  of
years ago, but it did  not give the  satisfaction its
advocates promised,  although  in  combination with
any of the bromides, it gave better results in modify-
ing their depressing effects, and in seeming to increase
the sedative action of this class of  drugs.   It  is not
to be forgotten  that it  is a  very uncertain  drug,
either in its natural state  or as an alkaloid, hence the
necessity of caution in its administration.
  Paraldehyde, which belongs  to the alcoholic series,
is a good sleep producer.   Like alcohol, it first acts
as a stimulant, then as a hypnotic, on the brain, then
upon  the cord, and when  given in dangerous doses
upon  the medulla oblongata.   The sleep produced  by
it resembles the natural sleep.   The dose ranges from
forty-five grains to two drachms.  It is best given in
mucilage flavoured, or in liquor diluted and hot.
  Sulphonal  is a  good hypnotic  in  cases of  mania
and  melancholia.  It  operates  in  about four hours
after  being taken.  It has no taste, and can be given
in a  cup of  coffee   or tea while hot without the
knowledge of  the patient.  It is hard to dissolve, but
will do so if put into boiling water and then allowed
to cool sufficiently to  be taken.  It can be given  in
syrup  or in  the form  of  a pill.   It   is more of a
sedative  than a narcotic, and  seems  to act on the
system about  forty-eight hours ; sometimes a second
dose is not needed on the  following day.  This con- 
218
MENTAL DISEASES.
tinued effect may exist because  of  its  slowness  of
absorption.   The dose is from twenty to forty grains.
   Many of  these quieting medicines may disappoint
the physician;  then it may be well to  fall back upon
a combination of bromide of potassium and cannabis
indica.  This mixture may not narcotize.  I  am not
sure but this is an advantage  as  far as  the  brain  is
concerned, for it means less interference  with normal
blood supply, and does  not  increase the  congestion
already existing in mania.
   A number of cases  of acute mania of the mild form
are treated at home by the family physician.   Many
such  recover if  sensibly nursed,  fed  and properly
medicated.   Exhaustion and inanition  are  tugging
at the heart strings, so pabulum must be provided  to
prevent death by keeping nature's reserves up to the
normal strength if possible.
   The tireless builder, who is making heroic efforts
to keep the structure  in good repair, is crying out for
material, and that of  the right sort.  In acute mania
the crisis comes soon,  and our opportunity to tilt the
nature towards recovery has  to  be taken advantage
of at once, so as to possibly save  from death  or  pre-
vent a lapse into a chronic and  incurable condition.
In treating such it may be laid down as  an aphorism
that medicine might be dispensed with and recovery
take place ;  but that  cannot be said, as a rule, with-
out nourishing food, cleanliness  and fresh air.   The
former is  merely a valuable  adjunct to  the latter,
but it is not to be despised nor neglected.  My  repe- 
TREATMENT OF MANIA.
219
tition of this rule of practice shows how important it
is in my estimation.
  The quantity of food which a patient consumes  is
to be considered in relation to what he digests.   To
cram food into  the stomach of a patient who is some-
what physically exhausted without considering how
much of it  may  be used  by  the body does  harm,
especially when the stomach is throwing out in various
ways signals of distress.   We should do our best to
favour proper digestion and assimilation ; if not, then
will we have mal-assimilation  and mal-nutrition from
engorgement.  We have to consider the right selection
and proper administration of  food.  The nitrogenous
or animal and carbo-hydrates or starchy are the  two
groups of food which our  knowledge of  chemistry
suggests.   We have  the  representation of  the  first
class in flesh, milk, eggs and  fish.  The second kind
is represented by the  different grains, vegetables  and
fruits.
  Animal foods supply material  for the building up
of the tissues of the body, while starchy foods supply
the  fuel, the burning  up of  which  in the chemical
processes which are constantly going on developes the
energy necessary for the carrying on the activities  of
the body.  In mania both classes are required in tissue
building and in fuel producing.   A uniform and  con-
tinuous diet  is  not  as satisfactory as  are changes  of
somewhat similar food.  The stomach  takes kindly
to varied food in disease as well as in health.
  In any form  of mania it should be a first principle 
220
MENTAL DISEASES.
not to use any soporific if it can be  dispensed with.
If a patient can even only procure  three  hours' sleep
in the twenty-four hours of the day, it is better than
any length of time  in  sleeping because of the toxic
influence of  any drug.   Medical  brain restraint  is
only  to be  employed  as  an auxiliary when nature
fails.   It  gives  the struggling and  exhausted vital
powers a chance  for life, but the  dispensing of such
potent agents should  be discontinued  at as early a
period as possible.  Three  hours'  natural sleep may
be followed after a few nights by four or five hours
of sleep ; and, as a rule, as the sleep increases the mania
subsides.  This is always a good sign, especially in
acute cases.   No powerful narcotic  or sedative should
be used continuously day after day, except  in  great
emergencies.   It is  well  even  intermittently to let
nature get on its  fe'et and  have a chance to throw off
its thraldom along natural lines.  Spitzka truly says :
" It is not so much the object to  crowd  down a
psychosis  as  to  establish  a series of relatively lucid
periods, and thus to tip the scale sufficiently on the
side of struggling nature to  overcome the pathological
influence.   It should be borne  in mind  that  mania
disappears not suddenly, as  a rule, but by a series of
oscillations  between the  healthy  and the  diseased
state, which  finally  merges into  a healthful  equili-
brium, and, in the absence of a specific remedy, it is
wisest to follow physiological lines of treatment.  No
mania was ever choked down, but at most prolonged
or diverted into  the  channel of deterioration by the
excessive use of  hypnotics and calmative  drugs." 
EPILEPSY, MASTURBATION AND MELANCHOLIA. 221
CHAPTER XXIY.
EPILEPSY,  MASTURBATION AND MELANCHOLIA.
There are a great many remedies lauded in the treat-
ment of the various forms of epilepsy.  That is usual
in these days of polypharmacy, especially in relation
to the  intractable  diseases which baffle our  skill  and
defy our efforts.
  A few years ago  amyl-nitrite  was extensively
advertised as a cure for epilepsy.  This drug  produces,
as far as known, no special effect on the brain beyond
the dilatation of the cerebral vessels, and, as a conse-
quence  of its action, there is a sensation of fullness
and  oppression in the head.  It lowers the  reflex
irritability of  the  spinal cord.   After a brief inhala-
tion of it, the action of the heart becomes exceedingly
rapid,  the face flushes and a violent throbbing in
all the arteries is  experienced.   That  the vessels are
enlarged we have evidence, not only from the flushing
of the face, but also in the  congestion of the retina,
and by the free flow from cupped surfaces, which had
previously yielded only a  few drops  of blood.   This
effect is said not to be  produced by the influence of
the vaso-motor system, but depends on a direct action
of th e drug on the muscular coats of the arteries.  It 
222
MENTAL DISEASES.
has also been asserted that it diminishes oxidation of
blood.
  During the year  1877 we gave  this  remedy an
extensive trial in epilepsy   Twenty-nine  epileptics
took it for some time, and nearly all were  benefited
by it.  In some cases the fits ceased altogether  for a
lengthened period; but, of course, there is a periodicity
in their invasion which must be taken into account.
In other cases the attacks, under the administration of
the drug, were as frequent  as  formerly, but not  so
severe  nor of the usual duration.  Some of  the  more
intelligent patients told me that, since taking the drug,
when  they  felt  that peculiar sensation which  some
have before the  attack,  they had strength  of will
sufficiently strong to overcome it.  A third class had
fits, but much fewer and less severe than  formerly.
All these cases had been  treated  in the  orthodox way
before  using  this drug,  and without any  decided
benefit.
  It is impossible to say with any degree of exacti-
tude what may be the condition of the brain  in such
typical cases, but in  this  asylum a large proportion of
such cases were anaemic.   It did not do well with  the
plethoric.  From the well-known effects of  this drug,
in producing a  temporary turgescence in  the  blood
vessels of the head,, it  is  highly probable that  the
medicine  acts beneficially by its static effects on the
blood,  and not by any direct therapeutic value it mav
have on  the disease.  Whatever  may be its way of 
    EPILEPSY, MASTURBATION AND MELANCHOLIA. 223

working, the condition induced is no doubt antagonistic
to the epileptic aura.
  The  method of administration was by the inhala-
tion of four or five minims at a time.   It is put up
by some  chemists  in small glass beads, and  can thus
be carried in the  vest-pocket.   All .that is necessary
for the patient  to do is to crush one in a pocket-hand-
kerchief  and it is ready for use.
  In nocturnal epilepsy, or in the masked or  larvated
form, strychnia is often very efficacious in  doses  of
l-30th of a grain three times a day, gradually increased
to l-15th of a grain.  This is an excellent remedy, if
there is with the fits any gastric derangement.
  The  debilitating effects of the continued-use of the
bromides in patients already weak, as are most epilep-
tics, ought to be prevented or lessened by the use of
strychnia, arsenic or cod liver oil, and a generous diet.
  In making use of strychnia or  arsenic, it is not to
be forgotten that not only  the  bad influence of the
bromides but  also their favourable influence against
epilepsy  can be diminished  by these  powerful agents
(especially strychnia).   It is therefore necessary, when
these agents are used, to increase the quantity of the
bromides.
  As a rule, epileptics  do not do  well  on iron and
quinine,  unless there exists anaemia of a pernicious
nature—chlorosis or cachexia from malarious poisons.
  Curare and  picrotoxine have their advocates, but
they are of  doubtful efficacy.
  The bromides are at present  the great remedies to 
224
MENTAL DISEASES.
cure or modify epilepsy.   This is the testimony of the
profession, in spite of many so-called specifics, which
have had temporary ascendancy, but soon disappeared,
to be succeeded by equally ephemeral drugs.
  The action of the bromides on the human system is
general.   It affects the nervous  and muscular struc-
tures in every part.  It acts as a nervous anaesthetic,
and  also  on  the  mucus and integumentary  surfaces.
It affects the muscular organs of digestion, respiration
and  urinary excretion.  Its sedative  action on the
circulation, its partial  effect on the  temperature and
on  the various  secretions show perfectly  the uses
which have been  made of this salt, without explaining
its action on  any  special organs or on local parts.
  It is by its anaesthetic and sedative action that it
controls  the  most extensive and complex neuroses,
such as hysteria, chorea, hystero-epilepsy and  epilepsy.
These haloid salts also act upon local  nervous affec-
tions, such  as dysphagia, whooping cough, asthma,
spasmodic dysuria,  spermatorrhoea, and where there
are isolated morbid conditions such  as we find in the
neuralgias and rheumatism.  Its sedative action con-
trols the circulation, and  renders it a suitable  agent
for the removal  of  any hyperaemia, whatever  be its
extent or situation.
   While the bromides and iodides are thus invaluable
in many of  the neuroses,  either alone or in combina-
tion, it is not well to give them  continuously too long
at  a time, lest glandular insufficiency might  ensue 
    EPILEPSY. MASTURBATION AND MELANCHOLIA.  225

thereby, or it might be a temporary paralysis, because
of induced muscular weakness.
  If a bromide has  to  be given  regularly for some
time, to avoid the unpleasant results of Bromism, it
is better to give the zinc bromide salt, say :
  R  Zinci brom.........................  3ij-
      Syr. simpli.........................  3J.—M.
  Dose:  Ten  to thirty  drops, three  times  a day,
gradually increased.
  This  form  is  a  powerful tonic, and will neither
upset the stomach, nor produce  cachexia, nor skin
eruption, even if given six months at a time.
  We have found the same beneficial result when
borax is used with any of the bromides.  In Germany
and Russia the bromide of gold is lauded in epilepsy
and a mixture of gold chloride and  arsenic are given
in these fits, as  well as  in  locomotor ataxia.  It is
possible the efficacy lies a good deal in the attractive
name, as  in the  much  praised cure for dipsomania
from the same source.
  Hydrobromic acid  is  a sedative  neurotic like its
salts, and  is a good occasional substitute or alternative
for  them.   The bromine in this  acid  state is  not so
liable to enfeeble the muscular  tissues nor produce
that alkalinity  of  blood and  of the  secretions, nor
weaken the digestive and assimilating process which
the long use of the  salts does.  It is also pleasant to
take.   It  is often  beneficial  in solution  with one  or
more  of the salts.  Less of both  is required if corn-
    15 
2^6              MENTAL DISEASES.
bined.   In this way  the  alkaline  saturation  of  the
system is avoided.  For example, when an epileptic
may be taking 25 or 30 grains of potassium bromide
three or four times a day ; the dose can  be reduced
to 15 grains a day,  if 6 or  8 grains  of  this acid are
added to each dose in solution.  Be sure to give plenty
of fluids with any of the bromides.   It is well not to
give any of the bromides, and  especially  the iodides,
on a full stomach, as their  effect is not  good  on the
starch of foods.
   The following prescription, first  recommended  by
Dr. Brown-Sequard, will often be found  to do good in
epilepsy of the idiopathic form, and often when other
remedies fail.  It is well  known by the  profession :
     R   Potassii Bromidi............."1
         Sodii Bromidi................ Ua  3iij.
         Ammonii Bromidi............J
         Potassii Iodidi...............Uk  3iss
         Ammonii  Iodidi.............J
         Ammonii Carbonati............ .    3j-
         Tine. Calumba?  ..............    3JSS-
         Aquae................q.s. ad fit    gviij.—M.
   Sig :  A teaspoonful and a half an hour before each meal,
 and three teaspoonfuls at bedtime.
   In  hystero-epilepsy I have found a  good deal of
 benefit in  some cases in the use of a one per  cent.
 solution of nitro-glycerine (Glonoinum).   Dose : One
 to three minims.
   It will thus be  seen  that the remedies used are 
EPILEPSY, MASTURBATION AND MELANCHOLIA.  227
principally those of antispasmodics and sedatives.  A
combination  may be given in the following formulae ;
    R   Potassii Bromidi.........) A A
         ^, ,   , „ ,              > aa gr. xv. to xxx.
         Chloral Hydrat..........j    &
         Strychnia? Sulph...........    gr.  iV
         Ext. Ergota?..............fl.  ~,ss.
         Ext. Digitalis  ............fl.  m. j.
         Spt. Mentha? Pip...........    m. v.
         Aqua?  ................q.s.    5SS.—M.
  Sig: One such dose after morning and evening meal,
with water.
    R   Potassii Bromidi.........) A A
                                  > aa  gr. x. to xx.
         Sodii Bromidi...........J
         Ext. Ergotee..............fl.   3ss.
         Tine. Nucis vom...........gtt.  v.
         Atropise Sulph.............    gr. t.t0.
         Spt. Menth. P..............    m. v.
         Aqua? Dist.................    §ss.—M.
  Dose : As above.
  The " enshrouded moral pestilence," masturbation,
is often prevented by  means of passing a fine silver
wire  through the prepuce and  knotting it  so as not
to strangulate the part  inclosed.   This can  be left  in
for  months at a  time, and  while  in  situ  the habit
cannot be indulged in.  The same object can be gained
by vesication; but it must not be  extensive nor  long-
continued, lest disagreeable cicatrices and contractions
should be  the result.  The  induction of   Bromism
often takes away the erotic desire,  but it must not be
pushed  too far, lest semi-dementia should be induced. 
228
MENTAL DISEASES.
If the patient has any will-power left, he may be able
to control  the  vicious habit  by keeping the  parts
clean and by the  application of ice-water  when  an
impulse comes on, unless the desire is  purely psychi-
cal.  The hope of  cure  lies in the  period antedating
the invasion of insanity.  When brain disease sets
in the  habit may largely cease, but the mischief has
been done to the great nerve-centres.
  The incurable and intractable disease, Progressive
Paresis, in its first stages requires to be treated with
sedatives.  As it  progresses, the  most of those thus
afflicted  find  their  way  to  some  hospital  for the
insane to end their days there.
  The syphilitic  form may  be staved off for  some
time  by the  use of such  remedies  as  Donovan's
solution, or  some other form  of mercury and arsenic
with the iodides.
  The mania of paresis is treated very much as are
any of the other manias.
  A pill of valerianate of  zinc and  extract of Bella-
donna has good  results  to allay the  restlessness  so
often seen in the daytime.   It  has little effect on
positive mania.

            Treatment of Melancholia.
  Remember that in melancholia  the condition is a
weakening  and a diminution of the  tension of the
nerve  currents.   Treatment  must  be directed  to
arousing a more intense activity in organic life.   The
process of  storing energy  in the nerve-cells is a part 
    EPILEPSY, MASTURBATION AND MELANCHOLIA. 229

of the general work of  nutrition.   If we can by any
means increase the activity and vigor of the nutritive
processes  generally throughout the  body,  we can
compel the nerve-elements  to take a  share  in the
increased activity, and  may, by degrees, restore them
to their normal state.
   First among  the  restorative measures  is the ad-
ministration of food.  Hunger is wanting, hence poor
eating ; but the taking of aliment  must be insisted
upon.
   Dyspepsia  may  be  present of  the  atonic  form,
which  so   frequently  co-exists   with  the  mental
depression.  This  fact  should not prevent the  ad-
ministration  of  food.    Abundance  of  food  must
always be administered, no matter what the state of
the  patients  digestion may  appear to be,  and  no
matter how directly contrary it may be to his inclina-
tion.   It is not enough to give slops and concentrated
essences of meat and peptic fluids; solid food of varied
nature is the sheet-anchor, if the greatest benefit is to
be obtained.
   To  assist digestion,  reasonable  exercise and fresh
air are needed,  not to speak of  cleanliness.  The
tendency is to sit  and  brood over imaginary  ills.
Ordinary cleanliness is  often neglected.   The friends
are  often  poor nurses  to  see  to  sanitary conditions.
For insomnia, opium, or choral, or sulphonal or some
of the bromides are resorted to.  My experience is that,
as a rule, a patient is better without any of them.   A
natural sleep  of even  three hours  in the twenty-four 
230              MENTAL DISEASES.
has more restoration  in it than has  any number of
hours in stupor or in drugged quietude.
  Of  much  more  avail  are  drugs—such  as iron,
quinine,  arsenic and  strychnine—which   tend  to
stimulate  the  processes of digestion and of nutrition
generally.  I have found  good  effects from the syrup
of  the  phosphates  of quinine, iron  and strychnine
(known as Easton's  syrup).
  Beware of  indulging in too much purgation.  A
laxative is needed sometimes to unload the colon, but
there  often is costiveness because of empty bowels, in
which condition  drastic  remedies  would do injury.
Good  feeding alone leads to peristaltic action of the
bowels.   The best aperients are some of the mineral
waters  given  fasting in  the morning.    If  there is
exhaustion from continued sleeplessness (and, of two
evils,  the  less has  to be  chosen)  administer  a full
dose at  once of the sedative used.
  There is so much  hope in so many of  these cases in
the acute  stage that we are encouraged to persevere
in all methods  conducive to  health, and  which are
taught to you in your Practice of Medicine lectures.
  It is  well for you to intimate to the relatives of
patients that usually recovery  is slow, so as to keep
them  from wearying with the  physician and  usuallj*
seeking succour from charlatanism.
  I repeat, again, that I find it a very common practice
to give  sedatives, such as the  bromides and  hydrate
chloral,  or  both combined,  to produce   temporary
relief and sleep  to  the patient, and also to satisfy 
     EPILEPSY, MASTURBATION AND MELANCHOLIA.  231

the urgent demands of relatives and friends to give
something  to  procure  sleep.   In this  way stupidity
can be produced, but not a natural sleep.  The nerve-
centres are, for the time being, benumbed.
  Patients afflicted  with melancholia  may,  at  any
time, manifest suicidal  tendencies;  hence, constant
watchfulness  is  of the  first  importance.  If the
patient's friends are wealthy, and can afford all neces-
sary accommodation and competent nursing, then are
home and its comforts  and surroundings a good refuge
for  such, unless delusions  of  persecution by friends
exist.  These  would, in their effects, antagonize  any
benefits  home  might  otherwise bestow.   If these
favourable conditions do not  exist, then is  a retreat
or an asylum, with its  treatment, imperatively needed
at the outset.  Unfortunately,  at  home  and among
friends,  there  are  not that  firmness  and kindness
combined,  so  necessary to cause the patient  to eat
well and to receive  necessary exercise and  air.  Too
often friends allow their sympathy to get  the better
of their judgment—the heart to control  the head—
and  as  a result, because  of  the  want of  necessary
attention, the  patient suffers.  There  may be,  and
usually is, great constipation,  especially in  the colon,
yet this  irritating state  is not attended  to ; there
may be  refusal of food, and  firmness and  skill may
be wanting to see  that  sufficient is  administered;
there may be  no sleep, and  consequent  exhanstion,
yet little attention  is given to the insomnia;  the
patient may care little about personal cleanliness, and 
232
MENTAL DISEASES.
it requires tact  and firmness to insist upon it being
attended to.   These, as  well as many minor  atten-
tions, which in the aggregate mean much in successful
treatment, need intelligence, firmness, kindness,  dis-
cretion and knowledge in the nurse.
  Many  such cases require  to  be  fed against their
will, especially if  they think that all  food given to
them is poisoned.  Some will  take  food by coaxing;
others require to be fed with a spoon;  others again
can only be fed with a feeding cup ; and, as a last resort,
the tube  has to be used.  Some prefer to use a rubber
tube, by passing it through  one of the nostrils well
back into the throat and oesophagus.   A large cathe-
ter  may be used in an extremity, with a tin funnel
attached.  Milk and egg will pass through  them by
gravitation.   A larger  tube and  more flexible, with a
hardened and  perforated end, is now used, and which
is better  in every way.   The stomach-pump is  not
difficult to use, unless the patient resists the tubes' in-
troduction between the teeth.  It will allow more
solid food to be  given than by  the  smaller tube
through  the  nostril.   If any of the back teeth are
wanting,  even with shut teeth food can be passed into
the throat with a child's  feeding-cup.
  We see now and then in the newspapers descrip-
tions of cases who have starved to death  at home,
through the culpable negligence of relatives or friends
or medical men, if called to  see  such  cases, and then
allow death to ensue  through want  of  food.  It is
criminal to allow it in the delusional insane, and many 
    EPILEPSY, MASTURBATION AND MELANCHOLIA.  233

are artificially fed for months, and make good recov-
eries.   I remember that, about sixteen years ago, one
of our medical  staff fed a young woman artificially
twice a day for a year and a half.  She had the delu-
sion that she had no mouth—personal experience to
the contrary.  It is not well to give opiates in melan-
cholia with  delusions.  In fact, if  delusions exist in
any form of insanity it  is well not to prescribe opium
or any of its salts.  It has only a tendency to increase
the malady because of consequent brain congestion.
   In  melancholia, accompanied by merely emotional
disturbance, opium  has sometimes excellent  results.
The deodorized tincture  of opium, with one  of  the
ethers, is usually well borne, with an occasional laxa-
tive to empty the  bowels.  Many such  have gastro-
intestinal catarrh with  the costiveness.   The tongue
is coated with a brownish-yellow deposit, and anorexia
is present.  This state  is largely brought about by
imperfect mastication,  or none  at  all  in artificial
feeding, and by insufficient or vitiated  secretions of
the stomachic fluids.  This condition  needs attention
by the use of the usual  peptonic remedies.
   Some patients cannot  tolerate  opium  in any form.
If so, other remedies  must be used if hypnotics must
be  given.   One  of  the  bromides  combined  with
morphia will often be tolerated, when either alone will
not be well borne.  As  is so often the case in medical
preparations, one drug modifies the action of another,
in some unaccountable way.
   The giving of nerve pabulum is not to be neglected, 
234
MENTAL DISEASES.
and we know that phosphorus in the chemical union,
which is easily disintegrated,  is more readily assimi-
lated.   The phosphides  excel  the  phosphites in this
respect, and the phosphites the phosphates.  Phos-
phorus is essential to animal life.   It is found in the
solids and fluids of the body.   If it is not supplied in
the food or by medicine, the result is mal-nutrition, a
neurasthenic condition and depreciated brain power.
In fact, phosphorus, in one form or another, has been
truly termed food, as it is present  in all cell growth,
and is indispensable to functional activity.
  As a rule, nitrogen and phosphorus  are  found to-
gether as builders'  material in the constructing and
repairing the physical system.   So  it will be seen how
important they are as sources of nerve force, and  the
stimulating  agents of nutrition, hence the importance
of supplying them  to the body in nervous diseases
and insanity.  Give material  in  proper  form  and
nature will perform the work.  Phosphorus in conjunc-
tion with cod liver oil, is an excellent combination, say,
1-100th to l-15th of a grain  at a dose.  Fats enter
largely into nerve composition, and it is necessary to
organic integrity that the hydro-carbonates  should be
administered artificially, or  built up in the system bv
nature's  processes from material  being furnished in
the foods.   The  fats are an  important element in
nerve structure,  as well as is phosphorus.
  In melancholia  we have mental depression, or a
sense of ill-being, to deal  with. This means  trophic
lethargy or deficiency, in whose sluggishness is loss of
physical activity, and, as a result, mental misery. 
    EPILEPSY, MASTURBATION AND MELANCHOLIA.  235

  It  is evident  that any useful therapeutic agent
must  be largely tonic.  In other  words, it means that
which will conduce to appetite,  digestion  and nerve
stimulation of  the vaso-motor  or trophic system.   In
our experience, quinine, phosphorus, strychnia  and
iron stand first in insane melancholy.
  Give as few sedatives  and narcotics  as possible.
Trust  much to fresh  air, wholesome  diet, cleanliness,
and gentle exercise.   Bromides are not borne  well in
such cases.
  A recent author  truly says:  " Quite  extravagant
hopes have been based on the  alleged curative effects
of electricity on insanity.  Superficial theorizers have
even undertaken to indicate  the  special kinds  of cur-
rents  and  directions of such,  to be applied to the head
in various forms of insanity,  and it is to be presumed
that the more  modern imposition of  static  electricity
will come  into vogue, and after a brief sway over the
minds of the credulous, and an  occasional success with
a simulating or hysterical patient, share the  fate of
other epidemics of charlatanism.  Electricity can have,
from the very nature of  the  case, no  specific effect on
insanity.  Its applicability is limited  to those in which
there  is simply atony, as in stuporous insanity, and to
those  which are associated with organic and functional
disease of  the  nervous axis.   In the  latter case  the
ordinary rules of electro-therapy apply.  In stuporous
insanity its effect is  to  stir  up  the  patient, but  we
should be  sure of our  diagnosis before  applying it,
and not confound atonic melancholia with  dementia, 
236
MENTAL DISEASES.
for in a melancholic  patient  electrical manifestation
and manipulation would probably  provoke additional
delusions of persecution to those he already entertains.
If we were better acquainted with the molecular con-
dition of the brain in health  and  disease, and  if we
understood better the exact influence  of electricity on
the atomic and dynamic states of that organ, we  would
be better able to formulate the  indications for the use
of this potent neurotic agent."—Spitza.
   There is a great deal of therapeutic value to get the
mind to think of something away from itself.  This is
especially true  of melancholia, in which the mind is
centered all  in  self.   If it is possible to get such to
employ themselves in work of any kind a great point
is gained.  To  work needs  attention to it, hence the
advantage obtained.   It also  means exercise.  No one
can be healthy  without it, much less  the insane, who
are not maniacal.   The  circulation is  languid ; the
nutritive processes  are slow, and need the natural
stimulation  which exercise  gives.  Amusements are
not  without their  influence for  good, and in  the
aggregate may  do more to bring about recovery than
we are  aware of.  They  are pleasant  recreations to
even the chronics,  and serve  to  beguile  the  weary
hours of an  otherwise monotonous life.
   Hypnotism has had its advocates in  the treatment
of delusional maniacs.  Those  who have  studied the
matter  must now attach no importance  to it as a
therapeutic  agent. 
HEREDITY.
237
CHAPTEE XXV.
                   HEREDITY.
It is not my intention to discuss  the general laws of
heredity, as manifested  in  biology or in natural his-
tory.   It is a great subject  in all its  phases,  and  it
must be acknowledged that,  as  yet, we are only on
the threshold of enquiry into  all  the latent and mani-
fest forces  and  potentialities which constitute the
existence and possibility of transmission of physical
and mental characteristics.  The  consideration of that
aspect of the subject belongs to the physiologist.
   Much has been accomplished in this field of investi-
gation by such  eminent  men  as  Lamarck,  Beale,
Spencer, Darwin, Romanes and  Weismann.  August
Wiesmann,  of  Germany, has  given recently to the
world  of  science  two volumes, ably written, on the
subject, and combats the Darwinian theory of  " The
transmission of acquired character/'
   It will thus be seen, in the  diversity of opinion,
that  fundamental facts  are,  as yet, only partially
developed.  Mercier,  the English alienist, truthfully
says :  " That the subject of heredity has been regarded
for  generations as having a  special  bearing  on the
subject of insanity,  ft is considered ominous for in- 
238
MENTAL DISEASES.
sanity to exist  " in the family."   The tendency of late
years has been  to lay increasing emphasis upon the
hereditary factor in this  relation.  In estimating the
influence of  heredity in producing a tendency to in-
sanity, regard has to be had to the number of instances
of insanity that have occurred  among the relatives,
direct or  collateral, and  of the  taint  of the patient
under consideration.  Heredity  has been considered
to exist  in those cases, and in those only in which a
record of insanity  has been found  among the  near
relatives."
   1st. This  estimate is liable to error.  The insanity
of the relative may  not have  been heritable, or  at
least remotely so, as, for  example, in general paralysis
of the insane.
   2nd. The  insanity of  the  relative and that  of the
patient under consideration may arise from different
sources, and not from a common  cause.
   3rd.  The factor which is inherited  cannot be in-
sanity per se, but may be an instability"t)r disordered
arrangement of nerve tissue, which allows insanity to
occur, and we must look for the bequeathed anteced-
ents of  insanity, not in insanity  itself as existing  in
progenitors, but in all maladies which display evidence
of undue instability or disorder of  the  highest nerve
arrangements.  For example, the nervous  peculiarity
which exhibits  itself as insanity in the offspring may
have become apparent in  the  progenitor, not as in-
sanity but as epileps}^, as chorea, as hystero-epilepsy,
as dipsomania, or in some other  form of nervousness. 
HEREDITY.
239
  ■ith. The law of transmission in a general descent
of characteristics is admitted, but it  is halting and
diverse in minor particulars.
  In genus " like produces like," but in species trans-
mission may not be identical, and, in fact, is not, as
children differ in many respects  from either or both
parents.   We each have a distinctiveness and person-
ality  in which we  differ from  every other  human
being, including progenitors.
  5th. Recently acquired characteristics are unstable
and evanescent in the human race.  The more recent
the appearance is of any character the more uncertain
is its  transmission; and, on the other hand, the  more
numerous the  generations through which  a character
has been transmitted the greater the certainty of  its
re-transmission.
  In  coming down through a long line of ancestry the
character seems like a falling body to gather momen-
tum, and  the further it has  descended and  the greater
momentum it has acquired,  the  less liable is it  to be
diverted from its course, and the greater is its power
to overcome any obstacle in the course of  its descent.
   6th. It is obvious that where  the attributes of the
parents are contradictory there are five possible alter-
natives as to the appearance of these traits of charac-
ter in the offspring, viz.:
   (a)  The offspring may inherit the attributes of each
parent solely, but not of both.
   (6)  It may  inherit  the qualities of one parent in
some respects,  and those  of the other parent in  other
respects. 
240
MENTAL DISEASES.
  (c)  The offspring may inherit the father's attributes
at one time of life, and at another  time of life those
may be displaced by the attributes of the mother.
  (d) The offspring may inherit a residue of charac-
teristics  of  both parents, plus acquired ones of the
child.  No one is moulded exactly after parents.
  (e)  The child may have physical resemblance to one
parent, but may have psychic similarity to the other.
The nerve centres are not subject to physical appear-
ances.
  (/) The power of transmitting latent qualities is
possessed by all highly-developed organisms, and this
law is exceedingly  important in its  bearings on the
occurrence of insanity.  " It may be written," as Dar-
win says, " in invisible ink, ready to appear on the
proper test being applied."
  There  seems to be a law of evolution and develop-
ment, in  which  attributes  tend  to appear in the off-
spring about the time of life at which they appeared
in the parents, and this is especially true of traits that
have  been recently  acquired.  It  is not merely the
successive changes of development to which this rule
applies, but also to other features, such as  nervous
defects.
  For example, in the family of Le Comte blindness
was inherited through three  generations, and no less
than twenty-seven  children and  grandchildren were
all  affected about the same age.   This rule is certainly
true in some cases of insanity.  In this institution at
present is  a  mother and  her  three daughters,  all 
HEREDITY.
241
accomplished and well-educated women.  The four
have the same form  of  delusional insanity, and have
had since the invasion of the  disease some ten years
ago.   Priorry tells of a family, every member of which
became insane at the age of forty.  Esquirol relates a
case in which  the  grandfather, father, and son all
committed suicide when in or near their fiftieth.year.
Of course, in many of these cases the law  of sugges-
tion must be taken into account.   At the same time,
the operation of this law may explain many an appar-
ently causeless  outbreak  of  insanity.  The latent
malign influence becomes the active agent of mischief.
   The seed, like that of the mustard  seed, lay in the
soil an inert germ until conditions favourable to its
growth gave it  developing energy.  When the degree
of kinship between the parents  becomes  too close the
offspring deteriorates in every  respect.  Hereditary
taint, when transmitted through several generations,
gradually leads to degeneration  somewhat in the fol-
lowing sequence:
   1st. In the first generation we find, apart from nerv-
ous symptoms, the disappearance of ethical feelings.
   2nd. In the next  generation a tendency to various
excesses appear, especially animalism and dipsomania.
   3rd. In the third generation there is  perhaps suicide,
or an affective  form of  insanity ; and,  finally, there
appears more profound forms  of mental disorders or
want  of development, such as  congenital  idiocy or
imbecility.
  If little new blood is  introduced  the race becomes
    16 
242
MENTAL DISEASES.
extinct.  It is not safe to establish  laws of heredity
based upon experiments on the lower animals.   Their
physical differences  and mental aptitudes have  not
that stability which we find in man.  They have  not
the variations found in man, nor have they the per-
sistency in forms and conditions of existence.  The
veterinary surgeons  can predict  and obtain results in
breeding which a law of selection could not obtain in
human beings.  In man's complex  organism the law
of inheritance of like qualities is largely modified by
laws of variation.  The son is not the exact image of
his father, nor of his mother, nor is he a simple mixture
of their qualities,  as he would  be  were  the  law of
heredity one of simple inheritance;  that is, of like  be-
getting like.  It is not possible to predict what will
be the exact  mental  qualities and bodily features of
the child  of  two  persons,  whose characteristics  are
very well known, nor so much as to tell what  its  sex
will  be.   Not only so, but in a large family of children
with the same parents no  two are alike in mind and
body.  Each  has a  distinct personality of its own.
Solomon, wisest of men, did not  trust his wisdom to
decide the quarrel  between the two  women about  the
child which  each  claimed to be hers.  The  resem-
blance of the child to one or  other  of the claimants
was not such as to found a decision  upon.   Twins, so
like in features and bodily outline, may and do differ
very much in their mental make up from one another-
  The Hungarian  twin-sisters, that lived  united by
their  backs  for twenty-two years, had  extremely 
HERedItY.
243
different temperaments,  although after  their deaths
their blood vessels were found to communicate, so that
the same blood served both.   The same was true of
the Siamese twins, who  died a few  years ago.  It is
also remarkable that a mother supplies the foetus and
child  for nine  months of  its intra-uterine life with
her blood, and  it has  been evolved  from her ovum,
yet she does not always stamp her whole individuality,
or any  of  it, on the  child.   We, in our  ignorance,
simply state that blood supply is one thing, and the
selective law of cells,  each according to its kind, is
quite another.
  Dr. Oliver Wendell Holmes, in his " Elsie Vernier,"
put the subject as follows : " There are things parents
can see, and which they must take account of in edu-
cation, but which few except parents can be expected
to  really understand.   Here and there  a  sagacious
person, old or of  middle  age, who has triangulated a
race—that is, taken  three  or more observations from
the several standing-places of three different genera-
tions—can tell  pretty nearly the range of possibilities
and the limitations of a child, actual or  potential, of a
given stock ; errors excepted always, because children
of the same stock are not bred just alike, because the
traits of some less known ancester are liable to break
out at any time, and because each  human being has,
after all, a small  fraction of individuality about him
which gives him a flavour,  so that he  is distinguish-
able from others by his friends, or in a court of justice,
and which occasionally makes a genius, or a saint, or 
244
MENTAL DISEASES.
a criminal of him.   It is well that young persons can*
not read these fatal oracles of nature.  Blind impulse
is her highest wisdom, after all.  We make our great
jump and then she  takes  the bandage oft' our eyes,
That is the  way the  broad sea-level of  average is
maintained, and the physiological  democracy  is  en-
abled to fight against the principle of selection, which
would disinherit all the weaker children.   The mag-
nificent  constituency  of  mediocrity, of  which  the
world is made up, are the people without biographies,
whose  lives  have  made a clear solution in the fluid
menstruum  of time, instead of being  precipitated in
the opaque sediment of history."
  The following points might be noted :
  Heredity  is the most potent cause of insanity in its
predisposing tendency.
  When it  comes  directly  from either parent it is
called immediate transmission.
  If it descend from both parents it is called double;
and if  from collaterals then have we converging fac-
tors.
  Simple heredity is its descent from either father or
mother.
  If it skip a generation and reappears it is mediate
heredity or  reversion.
  If it has existed  for a number of generations then
is it cumulative.
  When insanity appears in children at the same time
of life as it  did in the parent it is  styled homockron'
0U8. 
HEREDITY.
245
  It is anticipatory as to the  parental  disease if it
should  make  itself  manifest before the time it has
appeared in the parent.  It may be similar or it  may
be transformed into some  other form of nervous dis-
ease.
  It may intensify as the race continues and progress
to personal extinction, or foreign blood  may  be intro-
duced  which  would dominate  over the tainted  and
the  downward tendency,  when it might and does
disappear.   The fight towards health is the salvation
of our race.
  One parent being  insane is not as strong  evidence
of heredity as if  parent and grandparent or parent
and uncle, or aunt, or both, were insane.
  The insanity of brothers and  sisters is of little value
in respect to inheritance, unless strong extra  evidence
is produced to show the conditions of the life history
of each.
  Cousins may have very  near  blood relationship or
very little, as so much depends  on the  bequeathment
of foreign  or kindred diatheses.   For  example,  one
parent may  have a hereditary taint, or may have been
insane.  The other parent may have been the possessor
of good mental and physical health.  A  child of these
parents, as the saying is, " takes after" the father, for
example, largely in mind and body.  On account of the
dominancy of  the  paternal vigor in the child it may
escape the dangers which may lurk in the constitution
of the mother, and if this line of ancestry is maintained
with suitable marriages, in which there is no taint, 
246
MENTAL DISEASES.
then may the insane heredity die out.   The converse
is also true, and when there is a line of deterioration
intensified and  perpetuated by misalliances then ex-
tinction is the result.   It  will thus  be  seen that one
child in the family may escape this tendency when
another may be very susceptible to it, depending on
which parent  each  resembles the  most,  and  from
whom it  receives its inheritance.   Children may be
born before insanity attacks either or both  parents,
and children may be  born afterwards.  The former
children have immunity, and the latter have the tend-
ency downwards.
  It will thus be seen that the relationship of cousins
maybe very near if the similitude should continue along
the collateral lines, but remote if the children should
follow in  constitution  the foreign  blood introduced
into the descent. 
SYMPATHETIC INSANITY.
247
CHAPTEE  XXVI.
            SYMPATHETIC  INSANITY.
This is an old name  for a disorder of the brain con-
nected with  the disease  of a more or less distant
organ, which has no apparent biological  relation with
the brain,
  Sympathy is either  physiological or  abnormal;
sympathetic  insanity is a morbid sympathy  which
affects the brain in a secondary way.
  This  word sympathy,  when applied to  mental
troubles, was used as early as the  days  of Homer,
as  he mentions it in this relatio» in  his "Iliad."
Aristophanes has this term in his " Comedies."
  Hippocrates,  the  father of  medicine,  investigated
the relation  between mania and the  irritation of the
stomach, and has described  the mental  disorder con-
nected with  menstruation in young women.  Aretius,
an ancient physician of Cappadocia, places the seat of
mania and melancholia in the intestines.
  Galen  enunciated his famous theory of humorism,
and attributed insanity to the injurious  action  of the
bile.  This view of humors or moistures in the human
body held ground down to the 18th century.
  It  was  held that  there  were  four  principle 
248
MENTAL DISEASES.
" humours " or " moistures "  in  the natural body,
viz.,  blood, choler, phlegm and melancholy; on the
combination of which the disposition of body  and
mind depended ;  in other words, temperament, or the
tempering by mixture of these human elements.
  Humoral pathology meant morbid changes in those
four elementary humors or fluid  parts of the body,
without assigning any influence to the state  of the
solids.
  This  blood produced  phlegmon;  bile  produced
erysipelas, etc.
  These views are now known  to be fanciful; yet, we
know that all  the body has not only a community of
interests, but each part of  it is in intimate relation to
every other part in sympathy and function.
  It is not to be wondered at, then, that many excit-
ants to mental diseases are found primarily outside
the brain; as, for example,  some  uterine affections,
intestinal  wTorms, hepatic  suppuration, catamenial
disorder, heart  disease,  tuburcular  diathesis,  the
dyspepsias, and such  like.
  As I  have said before,  however, we are not to put
the effect before  the cause, as is  done so often  by
practitioners.
  Very often the reflex influence  is from the nerve
centres  to the organs.  So it would be bad practice
to treat the errant organ which is  only throwing out
signals of distress functionally.
  Sympathetic insanity may  be  naturally  divided
into two categories; 
SYMPATHETIC INSANITY.           249
  1st. Insanity produced by functional disorder.
  2nd. Insanity produced by morbid conditions.
  The  disorders  of  the former  class are  such as
puberty,  puerperal, menstrual, ovarian and climac-
teric insanity.
  The  disorders  of the  latter  are  such  as insanity
from diathesis, derangement connected with general
diseases and with neurotic conditions.
  Time would fail me were I to enter into details to
show  how  derangements of the digestive and  other
organs affect the mind.
  Esquirol and  Wichman tell us  that they  have
found displacement of the transverse colon a common
cause of insanity.  I have never done so.
  A large  number of the melancholy  are afflicted
with  some form  of  intestinal  trouble,   especially
duodenal catarrh.
  Organic  lesion  of  the liver is  not often found
among the insane, but functional derangement of the
liver and bile-ducts is quite common.
  The psychoses of renal origin are  not few.
  Although  diabetes is not actually primarily an
affection of the  kidneys, yet it plays an important
part in the causation of mental disorders.
  Thirst and polyuria  are often absent in patients
thus afflicted.
  Cardiac  affections  are very common among the
insane.
  Considering how much physical tone depends upon
heart action,  both as to  volume and  regularity, it is 
250              MENTAL DISEASES.
 not to be wondered at that its condition affects brain
 diseases.
   The puerperal condition is a powerful factor.   We
 see it in the eclampsias of child-birth.  A sane mother,
 in an hour or two after sanity has been lost, becomes
 a raving maniac, either from blood poisoning through
 the disintegrating uterus, or because  of shock in an
 explosive form to the greater and less sympathetic
 systems.  We know how great are the reflexes mani-
 fested in the ramifications of this manifold system of
 fibres and ganglia.   The vascular tone, the stimuli to
 heart  and  arteries, the influence on  nutrition,  the
 animal heat, not to  speak of the effect on  general
 pathology, all show the results produced through the
 influence of this system of nerves.
  The relation of one part to another is  strikingly
 seen  in  diseased  conditions.   For  example, facial
 neuralgia causes congestion of the conjunctiva and
 lachrymation;  salivation  occurring  in pregnancy;
 faintness or constipation due to irritation  of  hepatic
 or renal calculus; contraction of vessels and arrest of
 urine,  set  up  hy calculus in the kidney;  partial
 cramp of vasomotors, confined to the extremities of
 the fingers, seen sometimes in angina pectoris; the
 effects of cold on the vessels of the extremities, explain-
 ing various neuroses of the extremities; convulsions
from  teething,  severe  burns  or  bowel complaint;
tetanus from   a slight prick in, say, one  of the
extremities;  flux from the intestinal  vessels  is a
sequence of the irritation  of some foreign body in 
SYMPATHETIC INSANITY.
251
the canal, or  of  the collapse, from perforating ulcer
of stomach or intestines; contraction of cerebral ves-
sels may be caused by the irritation of  the proximal
end of  the divided posterior roots  of  the  sciatic  or
other spinal  nerves.   All show sympathetic rela-
tions.
   Sciatica may  induce  saccharine urine, the  fourth
ventricle being here the  centre of the reflex arc.
   Examples  might  be  multiplied  to  show  what a
community of interests  the  nervous system has, and
that  any  malign  influence  affecting  even  distant
parts, may and does  set  up brain disease and  in-
sanity.
   A number  of  authors give to us particular forms
of  insanity  as  being  allied  to  particular  bodily
lesions.
   They tell us that we may  expect one organ to pro-
duce  melancholia  when diseased, another  delusions,
another, it may  be, mania, another  stupidity, and
so on.
   This  coupling together specific  mental conditions
and definite  organic morbid states  is a classification
more  fanciful than real, as we know  that  no two
people are physically or  mentally counterparts of one
another, so diseased influences are never uniform in
their operations.
   To  the above list might be  added  as  active  or
predisposing  causes, rheumatism,  fevers,  syphilitic
poisoning,  the  various  cachexias,  gout,   scrofula,
pyaemia, and  such  like, 
252
MENTAL DISEASES.
  These  do  often  directly  and  indirectly  become
important factors in the production of insanity.
  In studying the life history of patients intelligently
the existence of one or more of these eccentric dis-
eases should  be diligently sought for, and their influ-
ence valued in brain disease.
  " Recent physiological and clinical  investigation
more and more tend to set  up the brain as the great
inhibitor and stimulator of all  nutrition; in  short,
the  master of functions  of  all  other organs and
tissues.   It influences strongly  both the blood for-
mation and the blood supply.  Any alteration in the
brain state has a more or less  trophic  effect on  the
organs of the  body.
  " On the other hand, we are coming more practically
to recognize that the condition of the nutrition of all
the  tissues and  organs affect  the  brain  directly
through the changes they produce in the blood, and
reflexly through their different nerves.
  " We are not surprised when  an attack of indiges-
tion causes irritability  and depression of mind, or
when impaired metabolism results  in  lassitude, or
when badly-working kidneys produced sleeplessness
with hallucinations of the senses.
  " The recognition of the action and  reaction of peri-
pheral organs and  brain is now daily experience in
medical practice.
  " This  clearly implies an intense  reactiveness of the
highest  of the brain functions,  manifested  in mind 
SYMPATHETIC INSANITY.
253
phenomena, to all abnormalities of function and nutri-
tion throughout the body.
  "The mental centre is necessarily the  highest and
the most universally related of all the nerve centres."
—Clouston, in Psychological Dictionary.
  These central truths show that in  our main divi-
sions  of the different forms of insanity  there  is an
artificiality which excludes too much the central fact
of a community of influence in all the organs focaliz-
ing in the supreme nerve centre.
  Unless these  sympathetic relations of the various
parts of the body to the  brain  are constantly kept
before the  mind in our diagnosis, then will  wTe fail to
understand and  properly appreciate  all the factors
influencing the object of our investigation. 
254
MENTAL DISEASES.
CHAPTEE  XXVII.
        THE BORDERLAND OF INSANITY.
                  Neurasthenia.
The name neurasthenia, or  neuratropia, is as good
as any term we can use to  describe this nervous dis-
order.  The class of patients to which this formidable
word  can be applied  is very large, and is growing
larger day by day in this nerve-exhausting age.  The
patient's  mind is " centred all in  self."  The woes and
aches  and pains such endure—real  or  imaginary—
and which are recited to  the physician  with  weari-
some reiteration are legion.   The old story is to such
ever new.  The history of these  multiform afflictions
becomes an old friend in its familiarity.  The  weary
doctor in his rejoinder can only encore his previous
homily to relieve  the recurring distress.  This sad
recital is repeated  from week   to  week, and from
month to month, until recovery or insanity  has taken
place.  The  concentration of thought on all the varied
moods and  feelings which the  patient may possess
intensifies the mental pain and aggravates the nervous
condition.   We know in our own  experience  how
much  mental anxiety or anguish depresses physical
function.  Fear  is more distressing than  pain, and 
          THE BORDERLAND  OF INSANITY.       255

tugs at the heart-strings with greater intensity.   Out
of this class  comes  the many suicides who are not
insane,  and  who  leave behind them sensible  but
woeful epistles to friends or acquaintances.
  In medical  literature this condition has been given
many names, such as cerebrasthenia,  brain exhaus-
tion, general  debility, nerve starvation, " run down,"
poverty of blood,  spinal irritation, and  other terms
" too numerous to mention."  This disease is not to be
confounded with hypochondria, hysteria, or insanity.
Each of these conditions is well marked and easily
discerned  by  any  observant  physician  The morbid
fears of insanity are usually definite and permanent,
and  accompanied  by  delusions, which  are  fixedly
believed in by the insane patient.  The neurasthenic,
on the other hand, will tell you how  unfounded are
their extravagant ideas, and that they can temporarily
banish these vagaries, but  only  to return again, like
the  swing of  a pendulum.    These  ever-recurring
whims pull down the physical energy,  and the bodily
depreciation  reacts  on  the  mental  until the nerve
masses and the physical  activity are mutually put
out of gear for the time.   The functional  want of
harmony is bordering on the  pathological.
  The  morbid fears of people thus  nervously  un-
strung are as varied as are  the individuals.   The
list of  their fancies and wild imaginings is endless.
All are  based on  some groundless alarm in respect
to themselves or in their  relation to others.   Men
full  of energy and push succumb to the depression. 
256
MENTAL DISEASES.
" Enterprises of great pith  and moment," which in
their best estate they would have taken hold of without
wavering, and have carried through successfully, now
paralyse them in  mere contemplation.   The brain
debility conjures  up lions in the way, or mountains
too high to climb over.   The fears  and forebodings
of indefinable  evil about to come, the unnatural and
morbid  dread  of  impending  adverse circumstances
have been the means of bringing about  commercial
or business disaster before friends see that worry of
months, and it may be of years, has been drawing on
the patient's stock.  The reserves of  the nervous sys-
tem, which we all have in store for emergencies, have
been consumed, and  the  fagged-out system has  no
alternative  but  capitulation, which it never  does
without a struggle.
  The   neurasthenic  may  be  divided   into  three
classes:
  1st. Those who complain of general weariness, be-
coming easily tired, having poor or capricious appetites,
being restless,  yet look fairly  nourished and  healthy.
  2nd. Those  who  are  evidently feeble.   They  are
usually  pale, thin,  and show generally a waste of
tissue and a breaking-down without any evident local
disease.
  3rd.  This latter class contains those  in which  we
find a hysterical condition and anaemia, especially in
chlorotic females.
  It is  well, however, in all  such cases not  to jump
too hastily at conclusions, lest  organic  and local 
          THE  BORDERLAND OF  INSANITY.       257

disease should exist, and  the  nerve conditions only
prove to be symptoms indicating permanent trouble,
which may need special and direct treatment.  I have
made mistakes mj'self in this  direction, and many
cases have come under  my  care in which my pro-
fessional  brethren  have been guilty of the same sins
of omission.   Be thorough in your examinations.
  All these  phenomena are  defects, outside of brain
disease, of a permanent character.  The identity is
not present, but the family resemblance is striking
in this brood of evils which border on insanity.   The
want of sleep, followed by a low power of thinking
in the pursuit of daily business ; the weakening of the
power  of  attention  and a  desire  to  wander  from
necessary thought; a shrinkage from doing a business
which heretofore was a delight; becoming abnormally
wearied in mind  when doing routine and ordinary
work;  not  the natural  facility to put ideas into
words, and an unnaturalness of temper in respect to
small matters and on small  occasions;  and  change
of manners and feelings to near friends and relatives
without any just reason, are cardinal characteristics.
We sometimes meet with the other psychical extremes.
such as unusual  and constant  buoyancy of  spirits,
mental exhilaration not natural, loquacity and flighti-
ness, which are observed by everyone except by the
individual himself.  So marked  are these changes of
character, that many  such  are  accused of  having
become drunkards.   The accusers do not know that
these symptoms are signals of  distress.  The  inde-
    17 ' 
258
MENTAL DISEASES.
cision of will, the bewildered judgment, the lack of
self-control and of discretion, the  excitement alter-
nating with unaccountable mental depression may be
only  temporary  and evanescent, or  they may  be
" coming events casting their shadows before."
  If there is any  hereditary taint of insanity, or any
serious  neurosis  existing, then  these evidences  of
physical and mental deterioration are not to be lightly
thought of, for any  such  condition may evoke from
latent tendencies  active  diseases  of  an  alarming
character.  The deficient mental  control of  sane peo-
ple thus afflicted  is a psychological study of  great
interest.  They know how absurd are  their fears and
forebodings, yet no reasoning can shake them  off or
remove the general nervousness.   The hopelessness,
the  silly fancies,  the  unnatural dread of being in
company or of being alone, the fear of contamination
in many ways undreamed of when well, the undefined
terror of walking certain streets or living in isolated
houses, and  the  general  sense of  ill-being  with a
dread of something vague about to happen, are only
a few of the many psychical conditions found in  the
neurasthenic.   The  most  pronounced  manifestations
underlying  these morbidly  tinged  conceptions and
misconceptions are timidity, irresolution, and constant
irritability of manners and speech not natural to the
person.  This state of feeling has a defined period of
invasion, and has not been gradually acquired through
daily experience  and repetition, nor is it a congenital
trait of character.  This abnormal condition is often 
          THE BORDERLAND  OF INSANITY.       259

the primary  stage of insanity.   It is interesting  to
note how conversely we often  find insane conval-
escents  show merely  this   modification of mental
weakness in the last stages before recovery.  Just as
the colours of the rainbow, or those  of  the spectrum
analysis,  blend  into one another  so imperceptibly
that no boundary between each shade can be located,
so it is  often difficult to know  by  observation, or to
define in language, where the dividing line is in many
cases  between  that disease we call  insanity and
nerve-starvation.  It is not, however, a fixed physical
disease, and,  does not effect  and control abnormally
the language and, conduct  of an individual,  as  in
insanity.  The physical  condition is  not to be over-
looked.  We often find abnormal dryness of the skin
and mucous  membranes, tenderness of the spine in
circumscribed places, as, we often find in hysterical
women.   Complaints of feeling heaviness of the loins
and limbs; shooting pains, simulating those of ataxy;
irritable heart-action,  best  known by a tremulous,
variable pulse, accompanied by palpitation and it may
be intermissions of  beats, mostly the third and fifth
beats.  Convulsive movements, especially on going to
sleep, which  have often  been mistaken for nocturnal
epilepsy; localized hyper-aesthesia; sudden giving out
of general or special functions; temporary paresis, or it
may be paralysis, and generally a feeling of profound
exhaustion unaccompanied  by  positive pain.   Some
graphically say : " They have a feeling of goneness."
   It need scarcely  be added  that these signs and 
260              MENTAL  DISEASES.
symptoms, as a whole, are not to be found in any one
patient, nor  are all enumerated in the above recital.
When  the imagination has full sweep, based  upon
feeble  or  no impressions,  then has  it  " no pent-up
Utica."  The  usual  diagnostic  and differential skill
will enable any one readily to  distinguish this disease
from either  hysteria or ordinary  anaemia.  It is not
chiefly found to exist in naturally  nervous persons.
  A patient may be  plethoric and  muscular—not
necessarily anaemic—and yet have  impoverishment of
the nervous system.   Neuratropia exists chiefly in
patients between  the  ages of twenty-five  and fifty
years.   Its  presence does  not depend on any im-
portant recognizable organic disease.  I have found
in a  majority  of cases  a full,  normal pulse, but
sometimes it is very  rapid, or  abnormally slow, with
a fluttering  feeling  under the  finger.   There  is no
cardiac disease present in most cases, and the face may
look the picture of health.  The  patients will often
apologize for their satisfactory appearance.   In spite
of apparent  strength, such are easily  fatigued  by
mental exertion, and  complain of  giving  out long
before the usual time of  resting.  The memory is
often temporarily weakened;  consecutive  thinking,
intense attention, or  sustained mental activity of any
kind, is found  to  be impossible, even when there is
no muscular fatigue.  It is at this  stage  when  in-
somnia is complained  of, usually  to  be followed by
mental depression and by distressing forebodings of
some impending calamity, which they cannot define. 
THE  BORDERLAND  OF INSANITY.        261
It is a general sense of ill-being and  ill-happening.
It is common to both  sexes, but is  more common in
the  male sex.    A  frequent  mistake  is  made  by
medical men in attempting  to  lecture such patients
out of their notions about themselves.   This will only
deepen  the morbidity  and intensify  the evil.  It is
best to  accept  the evil as a fact, but to raise hopes
for  the  future  in  a sunshiny  way.   This  is mental
therapeutics.
  No two cases  can be treated alike.  If it is a case
merely  of  brain exhaustion, then our main reliance
must be upon  vigorous out-door exercise  and light
mental exertion.  The muscular and organic life can do
much through activity in bracing up the nerve centres.
If we have an anaemic case, or  one in which there is
evidently exhaustion  of  the cord, especially in  the
chlorotic women,  then absolute rest and  quiet  are
indicated.   Digestive power and hygiene are  our
auxiliaries.  I am a great believer in alimentation—
not  over-feeding,  but  what the system  can  fully
assimilate.   It  is  nerve nutrition which we have to
do with, hence  the necessary pabulum must be pro-
vided.  Such usually  recover,  but gradually and so
slowly as to discourage patient, friends and physician.
The fact is, that all  nerve deterioration needs a
protracted  time to recuperate, and  it is well  to  set
out in treatment with this understanding by all, that
this depressing  condition has  invaded the nervous
system by slow approaches, and that it will leave  the
seat of  disease  with  reluctance, under the  most; 
262
MENTAL DISEASES.
favourable circumstances.   It is necessary to start out
with a large stock of patience in treating such cases.
  A close catechising of a number of young persons
has led me to believe that this abnormal  condition is
often brought about, or  at least intensified, by worry,
the vicious habit of  self-abuse, or from syphilis.  It
is also well to make  minute inquiry as to the exist-
ence of  the  mild form  of  epilepsy, especially of the
nocturnal or larvated or masked variety, which is
often overlooked, yet, by its enervating shocks,  not
only does it  pull the system down, but also  keeps it
prostrated when the mischief is done.   A rigid inquiry
on these points is of  paramount  importance in diag-
nosis of many cases.   I am inclined to think  that the
abnormal mental conditions are always secondary, and
that the primary trouble  is in the sympathetic and
spinal systems.
  The constant complaints of unusual  sensations in
one or more  of the abdominal organs are evidences of
this.  The heart's  irregularity, the atonic dyspepsia,
the obstinate costiveness, the kidney derangement, and
the temporary dyspnoea, all point to these great nerve
centres as the efficient causes of these derangements.
  If we  keep  in mind  that in  the  neurasthenic we
have  mostly to do with reflexes  of  the sympathetic
and spinal  cord, including all the organs to which
nerve stimulation is given from these centres  of influ-
ence and control, we can understand  how varied must
be the symptomatology of this generic disease.  If we
add to these disturbing causes a tendency to insanity, 
          THE BORDERLAND OF INSANITY.       263

or at least  find a nervous  diathesis predominating,
then, of necessity must our prognosis be less favour-
able.  I have found that those who  usually complain
of pain in the  back, show that the spinal nerve func-
tion is temporarily deranged.  This fact  is evident
when we find  the oxalates, the urates, and uric acid
in excess.   These are present only as results, and are
not pathognomonic, as in oxaluria, because on a return
of tonicity in the nervous system these  abnormalities
disappear.   They are at first only signals of distress,
which warn us of graver evils should the  disease in-
tensify and  continue.  The pathology of the disease
is not yet fully determined.  It may be a change in
the quality  or quantity of blood supply to the nerv-
ous system,  it  may be an impoverishment of nerve
force, it may  be bad nutrition  from low power of
assimilation—one or all of these causes, or others yet
unknown, would account for the exhaustion, the posi-
tive uneasiness, the unsteadiness, the fluctuating char-
acter of the morbid sensations and phenomena.  What-
ever may be the cause or causes, the result is nerve
starvation ;  the cry is for  more food and for  more
reserve energy.
   Let me summarize  the treatment:
   1st. Rest  and cheerfulness for the anaemic.
   2nd.  Outdoor exercise and  work for  the plethoric
and sedative.
   3rd. Fresh air, substantial food and absolute clean-
liness for both classes, as a rule.
   4th. No chloral, no opium, no alcohol; in short, no
artificial stimulant, soporific, or narcotic of any kind. 
264
MENTAL DISEASES.
Such short cuts to rest only murder natural sleep and
strangle the heroic efforts of  nature to come back to
normal conditions.  Even when these stilts are  used,
it must be after serious and thorough deliberation.
   5th.  Any employment which will have a tendency
to divert the mind away from self-contemplation: in
short, it is seeking relief by the law of substitution.
   6th.  I find the best remedies are such as the arsen-
ites, cod liver oil, zinc phosphide, ferri pyrophosphate,
nux vomica,  bromides with caffeine, zinc oxide with
ergot, and such like.
   These tonics and  calmatives  assist  nature to seek
again the  old paths.  Allow  me  to  add a word of
warning to the  younger members of our profession.
If sedatives, or narcotics, or stimulants are adminis-
tered it is well to mask them as much as possible.
We all know their seductive power, and I have  been
told by dozens of victims to  the alcohol, chloral or
opium  habit, that the first knowledge they had of the
pleasurable potency of such drugs was received  from
the family physicians.  After  their visits ceased the
remedy became  a  luxury, and  the  druggist was
applied to for the material to inflict infinite  injury to
many a valuable  life.  My method has  been  to use
seme menstruum  which would disguise the taste and
smell of these drugs, and  to maintain a  stubborn
silence as to their presence in my prescriptions.  This
warning is given here, as there is a great temptation
to use them in neurasthenic cases, in which are found
insomnia, local trouble, and mental distress. 
THE  BORDERLAND  OF INSANITY.        265
CHAPTEE XXVIII.
  THE BORDERLAND OF INSANITY.—(Continued.)

                   Dipsomania.

The dipsomaniac  has  our pity, but mere compassion
is of little moment unless it can take a practical shape.
Essays on alcohol and  on its physiological effects in
the human system have little power to reclaim an old
toper.  Moral tracts on the sin of this excess are mostly
thrown away on the confirmed inebriate.  Sermons
depicting the future fate of such are practically useless.
He cares next to nothing for his present or future fate
with a burning thirst for spirits  upon him.   Carica-
ture may do  its  worst; imitation of his stupid antics
and frolics may adorn  the  speech of  the  temperance
lecturer,  and  set his audience  in  a  roar of mirth ;
starvation and rags, filth and physical distress, scorn
and ostracism, all have no effect on the majority of the
pitiful victims  of  alcoholism.  Nothing  short  of a
miracle or a Divine  dispensation can save a vast
majority of those from  their morbid and debasing
appetite, if left to themselves.  The few are saved by
well-meaning philanthropists, but the many  are lost
to themselves and society.  It is,  therefore, a social 
266
MENTAL DISEASES.
problem, involving tremendous interests, how to save
these weaklings of humanity.
  The writer may be permitted to divide  the  drunk-
ards into four classes.
  1st. Those who become drunkards from a  habit of
tippling.
  2nd. Those who become drunkards from  drinking
to relieve nervous prostration, or to drown sorrow or
worry.
  3rd.  Those who drink to excess because of a heredi-
tary tendency to thirst after some stimulant or seda-
tive, arising from  nerve and brain  susceptibility or
depreciation.
  4th.  Those who become drunkards because of some
injury to the  brain, spinal  cord, sunstroke, or great
nervous shock of  any kind.  The  nature becomes
changed as well  as the character, because of  any of
these afflictions.   They influence the whole man for
evil, and that without a truce.
  Those who become drunkards from habitually im-
bibing are usually of three kinds.
  (a) The weak-willed, who cannot resist the tempta-
tion to imitate others in a drinking bout, or who may
think it manly to toss  off the  glass  with boon  com-
panions.
  (6) The  genial, jolly, companionable  fellow, who
loves company, and is usually good-hearted, generous
and free with his money.
  (c) The  mean-souled man, who cannot resist the
temptation to take a glass or two when others pay 
THE  BORDERLAND OF  INSANITY.       267
for them, or who delights to " sponge " on the good-
will and pockets of his more free-giving neighbours.
  Any or all of these varieties  begin to imbibe as
sober men ; but, by repetition, the custom becomes a
habit, and at last  it degenerates  into a  vice.   Such
stimulants  are  insidious, and often do their stealthy
work before the victims are thoroughly aware  of  the
mighty grip these  have upon them.  They wake up
to the fact that they  have generated and nursed a
craving want which it  is misery not to satisfy. Some
can,  by the exercise of great determination, refrain
from drinking in spite of the quenchless desire,  but
the man}' drift  down the fatal stream without making
one effort to reach  the shore of safety.
  Those who become drunkards by nightly potations,
to relieve mental trouble, are more numerous than is
supposed.   They are not usually found  among  the
drunk and disorderly in a police court; they may  not
make exhibitions of themselves in public places; they
may even give little trouble to their friends or families,
and many are  not even suspected of drinking until
a vicious habit has  been formed.  The  drinking is
done in  secret.  The victims pass sleepless nights,
and  as a relief drink  themselves nightly into pro-
found stupor.  It  is a drunkenness of which no  one
may  know, because the person has no excited stage,
seeing  he has at once saturated  his  brain  with  an
overpowering quantity of  the  stupefying  potion.
This  demoralizing habit may go on for years without
any particular symptoms being seen by others during 
268
MENTAL DISEASES.
the daytime, as the nocturnal drunkard will only take
a small dose in the morning to enable him  to  throw
off the stupidity of the nightly debauch, and to appear
as usual before the public.  This  truce cannot  last
long, and outraged nature takes the punishment upon
itself.  Paralysis, or apoplexy, or insanity, may  be the
result.  In many, before these sad inflictions  super-
vene, the  nightly  soporific is followed by the daily
spree.  The disguise is thrown off, and  there is a full
surrender to the persistent victor.   This class usually
belongs to our active members of society.
  The daily brain work above normal; the worry of
competitive business; the humdrum  of all work and no
relaxation ;  the fierce battle for life all along the line;
the envies and  jealousies in the world of fuss  and
fashion, which  end in  commercial ruin and  disap-
pointed ambition, and a  thousand such malign influ-
ences cause sleeplessness, mental anguish and general
nervousness.   Such victims flee  for  refuge to  any
temporary relief, and they find it most  readily  in the
oblivion of debauch from the use of alcohol or opium.
  It  might be  mentioned  here that  such  nightly
stupefactions are more fatal to mental integrit}T than
is any other form of drinking.  In such, the  excre-
tories have  not  time to  remove the  poison from the
system nor  the  brain to recover its tone from the
daily invasion, before they are again called upon to
defend the  citadel of life.   Each  assault  makes the
resistance more feeble, until, at last,  there  is uncon-
ditional surrender.  It really means  daily drunken- 
THE  BORDERLAND OF INSANITY.       269
ness up to the point of stupor and narcotism.  No
system can stand this constant strain and live out all
its appointed time.
  The third class include all  the  unfortunate victims
of a hereditary tendency.   These have bequeathed to
them a heritage of woe.   " Our fathers have  sinned,
and we bear  their iniquities."  It is not to be  for-
gotten that it is not drunkenness which  is inherited,
but only the nervous bias in that direction.   It  is a
sleeping lion, which is harmless until aroused.   It is
a magazine of dynamite, which is as inert  as a piece
of granite until rudely shaken or percussed.  It is a
battery of  electricity,  whose latent energy  is  not
known until a conditionfavourable to its manifestation
is created. Under a similar law this dangerous element
of  tendency  in a man's  nature  may remain  latent
until evoked by alcoholic stimulation.  The dormant
demon is then  aroused and will-power  is tied hand
and foot  by an infernal  tenant, which  no exorcism
can lay.  The paroxysms  come  on the  man  thus
stricken, intermittently, as do the periodic impulses of
some forms  of insanity.  The dipsomaniac  has  his
tidal wave  of all-conquering impulse.   Occasionally
men of giant self-control  belonging to this class can
successfully resist the burning desire to quench the
insatiable thirst  for alcohol.  They are the few, and
through  life  have an  incessant  struggle with  the
tempter.  These  are among  the  heroes  of our  age.
The man who has no taste for spirits can easily avoid
this temptation, but the  man to whom  the whiff of 
270
mental diseases.
liquor  from a bar-room  door as  he passes is almost
fatal to his integrity of purpose and sobriety has more
bravery in him, when he conquers his desire, and more
determination of will than has the soldier in a forlorn
hope.  The hereditary foe is conquered by daily battles,
and not by a few  isolated  repulses or assaults of or
against the relentless enemy.  This third class is com-
posed of persons in whom is easily discerned constitu-
tional disturbance before the  invasion of the periodic
outbreaks of dipsomania.
  Medical  men  can easily perceive  the unusually
nervous condition,  the irregular blood circulation, the
low nutrition, the  morbid  fears and forbodings, the
unnaturally irritable temper, the lack  of resolution
and firmness so foreign to  the individual in health,
and even misconceptions and delusions may supervene
when the attack  is  coming on.    The physical  and
mental conditions show undoubted signs and symptoms
of the coming outbreak which the victim cannot resist
any more than can the insane maniac. To blame such
a man to the same  degree as we may  those of the
other two classes  shows ignorance and injustice in
respect to  these unfortunates of inbred propensity.
During these  bouts  of drinking  mania  the  man is
uncontrollable.  He has inherited this defective tend-
ency.   What  in  an ordinary man might  be  very
moderate drinking is to  him destruction.  To  even
touch the fatal glass is to invoke the hidden energy
of incarnate  mischief which  has come  to him  as  a
sad legacy.  He is not to be put in the same category 
THE  BORDERLAND OF  INSANITY.       271
as is the man who, solely by his own habits, puts him-
self in an irresponsible condition by reason of this
drunkenness.  Such a person is  much  to blame for
the result  of his  voluntary  acts.  He could have
avoided being dragged into the  frenzy, which often
ends  in  direful  acts,  perpetrated on  himself  or
others, and so far is without excuse.  The person who
takes to drinking  to excess  by  imbibing largely at
bedtime, to relieve  nervousness and to  procure sleep,
may scorn the idea of doing  so for  pleasure, as. does
the tippler.   He usually declares that of two evils he
is choosing  the less, and treating himself medically.
His course of conduct generally ends disastrously to
himself, and cannot be excused or palliated.   He is
responsible for his conduct, as the method adopted of
indulging in  a  nightly debauch is voluntary,  and
medical  experience warns him of  its  danger.   He
oucht to know what  the end  must  be  when he  sets
out on this evil habit. It is astonishing what credulity
these people  have  in  their  own will-power.  They
positively assert that they can stop the  habit at any
time  they  choose, yet never make the endeavour.
With the most  of them this idea of  freedom is  a
delusion and a snare.  They boast much of what they
can do in throwing off the habit' but their vain-glory
is that of the braggart.  Seldom is the faith in them-
selves followed by practical results.  So faith without
works is dead.
   The  fourth class is  remarkable.  A sun-stroke, a
blow on the head, or a concussion of the brain, or of 
272
MENTAL DISEASES.
the whole nervous system often brings about a change
of character.   The  chaste  man becomes  suddenly
licentious in word and  action;  the  taciturn  and
dignified become  garrulous  and offensively familiar;
the brave become cowards ; the honest man can no more
be trusted ; the total abstainer, who never had a desire
or taste for stimulants, becomes an inveterate drunk-
ard,  not through tippling and  confirmed  habit, but
suddenly after any such nerve injury.  The whole
nature has undergone a complete revolution, and the
morals  suffer  first.  It is not a wickedness, but a
physical perversion which has  turned into a  new
channel or modified the moral and intellectual attri-
butes of such a man.   This condition might be called
insanity.
  Experience has shown that many of those who have
received a shock or an injury to the nervous system
are much more irritable than was formerly natural.
As might be expected, such are more  easily affected
by a powerful stimulant like alcohol, and its influence
is  more deleterious than  would be under  the  more
healthy  conditions.  As  a rule, the persons in this
class are more intractable, excitable, and even mania-
cal than they would have  been had no injury to the
nervous system taken place.
  It will be  seen, then, that we have floating about in
our midst, on the stream of life, these hapless slaves
to drink. We may eliminate from this vast army of de-
fectives those who could reform if they would only try;
yet a large number remain on whom no moral suasion
nor social nor Christian influences have ever had any 
THE  BORDERLAND OF  INSANITY.       273
effect to reform.  It makes the heart sad to see the
futile efforts of such to escape from this maelstrom of
depraved habits, but only finally to be sucked  down
remorselessly into its ever-devouring vortex.
  There is no  help  for these but enforced restraint.
They must be put in custody, where the temptation is
beyond their reach.   The Insane Asylum is no place
for them.   They need the same oversight as the in-
sane, but  different  surroundings  and medical  treat-
ment suitable to such.  To effect a cure, it is necessary
to provide them with healthy work, fresh air, various
amusements  and  nourishing  food.   The  buildings
should be  as homelike as possible;  the prison-like
should be  avoided, as far as  practicable.  Each case
has to  be studied separately and treated on individual
necessities.  The nervous system  is starving for its
usual  stimulant, and this acquired and morbid de-
mand must  be  met by the administration of natural
food and support.  Nature seeks  healthy highways,
if it  is  only assisted  in its heroic efforts  to return to
the old paths.  Were it not for these noble  efforts of
nature to seek its  primal conditions and throw off
this  man of the sea, woe betide drinking and drunken
Christendom.
  In the recuperative powers of  nature  is our great
hope in  rescuing these  perishing.   Many of the
wealthy  go  voluntarily to pleasant asylums  when
remorse is on them after a prolonged debauch.  The
desire  for drink may have left  such for  a time, then
are they in a penitential mood.   They readily  agree
     18 
274
MENTAL DISEASES.
to abide by the advice of the physician.  It proves to
be only as long as the lull  in the brain-storm lasts.
The irresistible impulse returns, and nothing short of
personal restraint can  then keep the  dipsomaniac
from his cups.  He cares  nothing for the conditions
of his bond ; he defies everyone ; he is lost to appeals.
He flies from  the  drunkard's hospital, and quenches
his intense thirst in  the intoxicating draughts.   We
casuists and moralists have not the faintest idea of the
agony  of  such a man,  seeking temporary relief to
quiet the raging devil in his surging brain.  At these
crises he is  irresponsible  and helpless.  Call  him  a
sinner, a depraved man, a  vicious citizen as you may,
but in the sight of High Heaven he  is held guiltless,
if no will  of his and no moral influence  can restrain
him.  In the first stages of  his  downward career he
may have been to blame, but now he is an object of
pity.  To hound such a creature in the last stage of
his career, because  he  at first brought  it about by
voluntary acts is cruel.  The man who becomes insane
by a sensual life, in which he is the victim of a loath-
some syphilis,is none the less an object of pity thereby.
  To reform any  such drunkard is a  difficult work.
A refuge must be provided for him with all the strin-
gent rules of a reformatory in active operation.  It
must be free to " the drunk and  disorderly," whose
depraved tastes  have brought  beggary and disgrace
on themselves, as well as  having an open door to the
rich.  The notorious and habitual drunkard, who has
become  a  pest to himself,  his  family,  and  society,
* 
          THE BORDERLAND  OF INSANITY.       275

should be  committed to an  inebriate asylum under
the same safeguards and stringency as are the insane.
It matters not whether the admission is accomplished
by voluntary surrender of personal liberty, or by com-
mitment of  a magistrate, or  by virtue  of  medical
certificates.   All or any  of these methods should  be
statutory, and should mean an indefinite and prolonged
term of oversight and submission to prohibitory rules
and regulations.  The great want in the Province of
Ontario is  the absence of  such  an  asylum to which
the poor can go for succour and cure.
  All such  institutions conducted on the voluntary
principle have failed, and  must fail  to cure chronic
drunkards,  however well these are  conducted.  The
principle of freedom to come  and go at  will is practi-
cally of no avail to cure.  This system  of providing
pleasant boarding-houses for a few weeks or months
away  from  bosom   and   boon  companions,  and
without  restraints, of necessity, cannot be  curative
establishments.  This  is their  record in Britain and
the United States.  A pauper drunkard has no needy
shelter to go to but the prison.   The  vast majority of
drunkards are poor, yet they need  to be  saved  from
themselves as well as do the  rich.  The state has put
in their pathway all the conditions necessary  to make
sots, inebriates and maniacs  of the feeble-willed, and
it is a pity that, after the cruel work has been done,
there is no haven  of refuge and cure for them.
   The longer a steady drinker of the tippling class is
kept from imbibing stimulants, the more easy is it for 
276
Mental Diseases.
him to continue a total  abstainer.   This is true of all
our habits  for good or evil, hence the importance of
endeavouring to undo a habit of excess by introducing
in its place a habit of abstinence and industry.
  A hospital to cure drunkards  should, in its opera-
tions, insist upon healthful  habits.   Its hygiene and
sanitation, its necessary discipline, the absence of the
usual  temptations  and associations,  the precept  and
example, the impossibility  of  indulging  the drink
craving, the gradual return  of  nerve strength   and
self-possession,  the power to refrain from seeking
this evil—all contribute to the recovery  of many who
could never be otherwise than chronic drunkards were
no restraint put upon their indulgence.  Many storm-
tossed and  pitiable  wretches, who are now bringing
untold anguish upon themselves and families,  and
who are a curse to society, as well as an expense to the
country in  our gaols  and  reformatories, might, in
properly-conducted  hospitals, reform and become use-
ful citizens.
  The experience of centuries has shown that we are
"wasting our sweetness on the desert air" to endeavour
to reform  these who are thus afflicted  by any other
means than personal restraint.  Religious  and moral
influences are not to be  despised when the despotism
of disease has passed away and reason begins to assert
its sway.  Noble efforts, by means of these agencies,
are continually  being made.   A few reform, who are
not too heavily handicapped in their struggle for
liberty, but  they are only the few of the  great army 
THE  BORDERLAND OF INSANITY.       277
of drunkards. Among this class of reformed drunkards
—so called—a large proportion relapse, unless they are
daily kept under the influence which incites to sobriety.
With them it is a daily fight for the mastery.
  In my official report of 1879 is the following para-
graph bearing on this subject: "Hereditary drunkards
must have the curse removed from them or they from
it.  The former is not likely to be done at present;
the  latter may be  carried out  under Government
supervision.  The  reformation  of  such is not abso-
lutely  hopeless, but  the chanees of recovery are  not
many;  yet  it is the duty of the State to  aid such
in their efforts  to reform ; and, if this be  impossible,
then it is equally  incumbent upon society to prevent
them injuring themselves or others.   The immediate
injury  done by such a drunkard to himself is  not
by any means  the worst feature  of  the  case.  If  a
child inherit to a  great  extent  the constitution and
individual  peculiarities  of  one  parent,  who is  a
drunkard, with no strongly marked traits of the other
to counterbalance  them, the probabilities  are  that  a
tendency to dipsomania will be  the  lot of some  un-
fortunate member  of that family not thus protected
unless  moral influence and early habits of abstinence
have kept in check the exciting cause.
  " The same rule which exists in respect to the insane
should prevail for  the benefit of these sufferers.  As
medical men it is  our privilege and duty to educate
the rising generation, our legislators, our ministers of
the Gospel and  our moral reformers  that  there is  q, 
278
MENTAL DISEASES.
class of inebriates who border on  insanity,  and who
are objects for medical treatment.  Experience teaches
that appeals to their religious  instincts  are in vain.
The moral nature is paralysed and utterly helpless to
control conduct.   The physical system through which
mind operates is out  of tune,  and nothing but  the
repair  which time and health can bestow will bring
concord  and harmony out  of  the instrument.  The
experience of  medical men  is, that nothing short of
personal restraint can cure the members  of this class,
and to whom is given the name of dipsomaniacs.   It
is as futile to appeal to  their manhood  as  it would
be to reason any maniac into  rectitude of  language
and conduct.  This mania is not confined to drunk-
ards.   Every druggist and  every  physician can tes-
tify  to  the increased number of  opium and chloral
consumers.  Those who have formed and are forming
the habit are  daily  increasing.   Many who  have
reformed in  their spirit-drinking habit betake them-
selves to such narcotics.  These drugs are stealthily
indulged in  as substitutes for liquor, and thus while
they have driven out one devil they have cohabited
with a dozen in his stead.   The former punishes with
rods and the latter with scorpions.   This is not  refor-
mation, it is only a change of intoxicants  to those of a
far more deleterious nature.  This habit  is more pre-
valent than is  dreamed of by social reformers,  and a
crusade is needed against the indiscriminate sale and
consumption of all such intoxicants. In this neuralgic,
nervous, sleepless and bustling age, this tendency will 
THE  BORDERLAND OF INSANITY.       279
increase unless a warning cry is  raised by  medical
men."

                   Narcomania.
  Within the last thirty years the use and abuse of
such narcotics as opium and its salts, chloral, absinthe,
chlorodyne, and such like drugs have increased an hun-
dred fold.  It is possible that alcohol, in all its baneful
effects, is doing less injury in the  world to-day than
these toxic agents.   Their victims  are not demon-
strative as are the alcoholic drunkards, hence are not
thrust prominently  into view.  The insidious effects
are produced quietly, unless at the  latter stages of the
morbidity  delusional mania should supervene  as  a
result.
  The Customs returns show how much consumption
of these and kindred  drugs is taking place,  after
making liberal deductions  for those used by the
medical profession.   The quantity is increasing  from
year to year  to a greater proportionate extent than is
the population.
  The causes of this increase in narcotics are many.
They may be classified under two heads:
  (a) Because of physical discomfort or pain.
  (b) Because of mental ill-being  or of some trouble
or distress, for which it is a temporary solace.
  The physical diseases for which an anodyne is taken
are as  many as  are all the  troubles which  afflict
humanity.  The  most  common,  however,  are the
neuralgias, headaches,  hysteria,  insomnia,  rheuma- 
280
MENTAL DISEASES.
tism,  cerebral  affections, hypochondriasis and sane
melancholy.
  The bodily symptoms are many in the narcomaniac,
and all are of a most distressing nature.
  The tremors, the temporary  ataxy,  the  organic
derangements, especially those of nutrition, the tro-
phic feebleness and consequent low cell  selection, all
point to serious derangements of  the vital activities
in all the somatic domain.  The victims of this habit,
when  it  has risen to  a vice, are pitiable objects  of
contemplation.
  Many of these  were at one  time alcoholic  drunk-
ards.   On account of the frenzy which spirits pro-
duced, and which made them  thereby the scandal of a
neighbourhood and a nuisance to relatives, they  change
the agent of mischief  to that of  one of these drugs
which satisfies their cravings.  If such should have an
inherited neuratic constitution, then is  their reforma-
tion one of extreme difficulty.
  The permanent mental symptoms, apart from  the
immediate effects of the drug, are  usually melancholy,
irritability,  loss  of  memory, suicidal  tendencies,
lowered intellect,  sometimes mental exaltation, and
always depreciated moral tone.  The loss of good habits
is almost pathognomic, and the depths of depravity
many  will  go to is scarcely credible.   This is more
true of opium  and its salts than of  drugs of  a more
evanescent nature, yet these untoward  results  depart
when  a cure  is  effected by  the removal  of  the
poisonous  agent, so it cannot rightly  be designated
insanity. 
THE BORDERLAND OF INSANITY.       281
  Treatment may be one of three kinds:
  1st. Sudden withdrawal of the drug.
  2nd. The deprivation being a little  at  a time, but
very slowly, extending over several months.
  3rd. The entire  withdrawal of the drug in, say, a
week or ten days.
  The first plan is cruel and  dangerous.   I have, on
several  occasions,  seen collapse,  heart  failure  and
death from  this method.  At other times delirium,
followed by mania, with delusions and hallucinations
of the most pronounced kind  are present.
  Half  a usual dose of the  drug given would drive
these away, unless permanent insanity should have
invaded the brain in the meantime.
  The second mode of treatment is adopted by many,
and has strong advocates in its favour. At the same
time, it is to be remembered  that it is  well to deprive
the patient  of the drug as soon as it can be  safely
done, and thus shorten his suffering to the least pos-
sible period, compatible with expected  success.
  The third method commends itself to my judgment,
and has been adopted with good results in a majority
of cases treated.
  No drug of a kindred nature should be put in its
place, even in insomnia; no cure  can  be  affected by
a change in  toxicants.  Codeine and cocaine have
been recommended as substitutes.  It  is  malpractice
to administer  them, as  experience has shown in too
many sad instances.
  If we can tone up  the system during the with- 
282
MENTAL DISEASES.
drawal,  especially by improving the  appetite  and
infusing moral  courage into  the invalid  to  exercise
will-power  against the  tempter,  half  the battle  is
won.   At the same time,  if such are free agents to
procure the drug before normal conditions are set up,
then  must  we fear collapses into the  former state,
especially in those of a neurotic  diathesis.  A goodly
number, however,  of  those at  large  recover  under
judicious treatment.
  My plan has been to gradually reduce the dose of
the drug so that at the end of, say, ten days its use is
discontinued.  In the meantime  baths and  fresh air
should not  be neglected.   Three times  a  day,  full
doses of  bromo-caffeine might be administered, which
should be given for some time after the noxious drug
has been entirely  withdrawn.
  The following prescription produce good results as
a substitute:
  R  Sodse  Brom..........................3J.
      Liq. Strychnia^......................31]-
      Tine.  Capsici.........................3uj-
      Aquse.............................3 viij.
  M.  Dose  : One  tablespoonful in  three tablespoonfuls
of water,  morning and  evening, at least one hour before
meals.
Or,
  Bs-  Zinci  Phosphidi......................gr. h-
      Extract Nucis Vom...................gr. 4-.
      Extract Cannabis Ind.................gr. J.
  M,   Dose : One pill of the above three times a day. 
THE BORDERLAND  OF INSANITY.       283
  If  a pure  preparation of  cocoa leaves is  used it
proves an excellent anodyne in the  opium habit.   It
is much more satisfactory than is the alkaloid  of  the
erthroxylon coca.
  For the thirst of inebriety  the following is good :

  R  Tinct. Capsici...................  1 drachm.
       Tinct. Nucis Yom...............  1 drachm.
       Acidi Nitro-hydrochloric, dilute. . .  1 drachm.
       Infus. Gentian............ad. . 12 ounces.
  M.  and  make mixture.  Sig. : Two  tablespoonfuls as
often  as three times a day.
  Or,
  R   Quinine Sulph.....................gr. ij.
       Zinc Oxide........................gr. ij.
       Strychnia Sulph...................gr. ~g.
       Arsenic..........................gr. T^D.
       Capsicum......,..................gr. ij.
  M.  et. ft. pil. no. j.  Sig. : One three times a day.

  Together with this pill, some use, for sixteen days,
the following hypodermic dosimetry :
  R   Strychnia? Nitrat.....................gr. j.
       Aquae Dest..........................oz. ss.

  M.   Sig. : Eight  minins daily  for eight days;  four
minims daily for another eight  days.  To  quiet the morn-
ing nausea of  alcoholics, two to  three drops  of  wine of
ipecac on the tongue, fasting.
  To induce  sleep the following sedative  is  admin-
istered at night for a few days : 
284
MENTAL  DISEASES.
   R   Tinct. Opii. Deod.............x
       Ext. Hydrosc, fid.............
       Chloral Hydrat...............>aa. dr. ij.
       Pot. Bromid.................J
       Tinct. Capsici.................... dr. ss.
       Tinct. Aconit rad.................m. v.
       Aquae Menth. pip............ad ..  oz. iv.
   M.   Sig.: Two tablespoonfuls at bedtime for a few days
only, freely diluted with water.
   If the patient is very much excited, and is border-
ing on delirium tremens, the following  is  useful  for
two or three nights :
  R   Hyoscin, hydrobromat.............gr. j.
       Aquae dest,......................dr. ix.
       Spt. vini. rect,  .....,..............dr. j.
  M. et. ft. hypodermic solution.   Sig. : Dose from five to
ten minims pro re nata.
  These remedies are also excellent in the treatment
of dipsomania, as  all toxic agents produce somewhat
analogous  results on the nerve centres. 
APHASIA.
285
              CHAPTER  XXIX.


                    APHASIA.
Aphasia is an affection of the motor speech region
of the brain.  The idea of what words are  required
for expression is correct, but the co-ordinating vocali-
zation is  impaired.   Wrong words  are attached to
correct ideation.
  It is to be distinguished from the merely functional
aphasia seen in hysteria or where deep emotion exists,
as these are only temporary.  The  incorrect  utter-
ances of the insane are not included in this term.  It
is not paralysis of the organs of articulation, such as
we meet with  in  hemiplegia or glosso-labio-pharyn-
geal paralysis.  It is not aphonia, for loss of voice is
caused by  impairment of the  vocal cords.  It is a
singular  dislocation between  the ideational centre
and the motor region.  The volition is rightly exer-
cised, but its command is not correctly obeyed.   This
lack  of  co-ordinating power  to articulate correct
words is called ataxic aphasia.  If there is added to
this condition loss of memory of words, then have we
amnesic aphasia.
  Among the first class there may be no apparent
mental disturbance,  but if the disease continue for 
286
MENTAL DISEASES.
any  length  of time, the substance of the brain be-
comes diseased to such an extent as to result in mental
lesion;
  Aphasia is  often accompanied by hemiplegia, and
both are frequently seen in apoplexy in aged people.
  The disease is usually caused by embolism of the
left middle cerebral artery, and, as a rule, is found in
the third left frontal convolution.
  The  uniformity  is not  sufficient to constitute  it
solely the distinct functional  centre  for verbal ex-
pression.
  The island of Reil, which lies immediately adjacent,
is often found to be the only brain substance affected,
including  sometimes part  of   the  corpus striatum.
This is not to  be wondered at  when we consider that
the same  blood vessel  supplies the  island  and the
second and  third frontal convolutions, where disease
is most often found in aphasia.
  When words  are  uttered with  the  meaning  of
which the aphasic patient  is  familiar and  they are
not comprehended, although the intellect is unaffected,
then there exists what is termed word-deafness.  The
sensory relation with  hearing and   speech is dis-
arranged.
  If words  which  may be written,  and which are
well-known to the patient in health, convey no mean-
ing to him, then have we word-blindness.
  Those afflicted with  motor-aphasia are often able
to utter words, and are not deprived of phonation.
  When the power to articulate distinct words is lost, 
APHASIA.
287
sounds can be made by the vocal organs, showing that
their powrer still remains.   Many such patients will
make intelligent signs, as  the intellect remains un-
affected.   It is only the  medium that is out of order.
If he  cannot understand  seen  words then  has he
alexia.  If his  healthy arm  and hand  cannot  co-
ordinate movements  to  write proper words, then has
he agraphia.
                     Amnesia.

  This is a disease of memory.
  1st.  The loss  of memory may be limited to a single
category of recollection,  leaving the remainder appar-
ently intact; these are  so-called partial disorders of
memory.
  2nd. Others affect the entire memory in all forms;
completely dissever mental  life ; produce chasms that
cannot be  bridged over.   These are called general
disorders of memory.—Ribot.
  The  different forms may be divided into :
  1st.  Temporary  amnesia.
  2nd. Periodical amnesia.
  3rd.  Progressive amnesia.
  4th.  Congenital  amnesia.
  In progressive amnesia the general  law of  experi-
ence is, that the more simple and early  impressions
are the longest retained.  The impressions remain the
longest which are received in childhood,  and, as a
physiological fact, must be retained in a primitive form
of the  brain, presumable in the medulla and in the 
288
MENTAL DISEASES.
basal nerve centres.  The physical  basis of memory
in its conservation and  reproduction depends on two
conditions,  (a)  Certain  modifications  of  cells,  (b)
Formation of  more or  less  complex groups of cells,
which  have   been called  "dynamic   associations."
This bald statement gives us  little light in the  ob-
scurity.
  There  is nothing more striking on the approach of
insanity in many than  mental  enfeeblement, as evi-
denced in lessened power of attention or lack of con-
centration of  thought,  added  to  impaired  memory.
This is especially true in progressive paresis.   Long
before  pronounced symptoms  are  observed,  trivial
matters connected with  every day life are unaccount-
ably forgotten.   Appointments, names, friends and
the days of the  week glide away from  the  memory.
The impaired recollections of many persons not insane
may not  rehabilitate at  will  some particular letter in
a word,  or some numbers in arithmetic,  or  one of
several well-known languages, or some other particu-
lar phase of knowledge  which was but slightly regis-
tered in  the mind.   It looks  as  if memory were
composed of successive  layers  of records, and those
last put  on are  first taken  off, or  that the  plastic
brain of  youth has had  events  and  experiences more
deeply engraven  on it than those of latter years, so
that in effacing  these reminiscences the shallowest
hieroglyphics are the soonest and easiest obliterated.
The  penmen who make these  imprints on the brain
are attention  and repetition.   If these powers  are 
APHASIA.
289
weak then are the fleeting ideas written on sand and
easily destroyed beyond power of recall.
  It is interesting to observe how  toxic agents,  as
well as  some forms  of  insanity, affect memory.   In
fever and on the approach  of apoplexy  memory is
often exalted in  a remarkable degree.  Past events
come back into  introspection with startling distinct-
ness.  The same  is true with narcomaniacs.   In the
insane utterances of those attacked with acute mania
this revivifying of forgotten past events  is noticed.
Not only so, but the mind seems enlarged in its capa-
city in some directions.   The sceptic becomes highly
religious,  and  may be a walking volume "on Evi-
dences of  Christianity."   The prosaic man  becomes a
poet,  and sometimes  shows himself to be no mean
rhymster.  The man to  whom arithmetic was a vexa-
tion glibly talks of figures, problems, and,  if qualified
by  previous  training,  of geometrical  puzzles.  Of
course, these evidences of  latent  power  coming  to
the surface  are  exceptional, yet their existence is a
wonder.   At first thought it seems almost  miraculous
that a person should be  deprived of all  recollection of
words and retain  the other faculties  of  the mind
intact; that he should forget one language and retain
his knowledge  of others; that a language long for-
gotten should suddenly  return, and one recently used
should for the time disappear as if it had  never been
acquired.  It is  not to be forgotten  how  unequal is
the memory of each of us in respect to past experi-
ences, and how intuitively we select  out of the past
     19 
290
MENTAL DISEASES.
facts in our own life history with more or less  vivid*
ness and correctness from among the millions of ideas
which  have  gone  into oblivion.   Not only so, but
new capacities are often  evoked not known at first
even in the normal state.
  If memory on its physical side depends upon blood
supply to the cells, then would it seem that not only
does increase of  blood  circulation to  the tens  of
millions of  such  bodies make these enlarged powers
possible and probable, but  also the extra blood supply
may raise  to psychical prominence tracts   of  nerve
energy not  made manifest before.
  We know that all the wild and impossible imagin-
ings of dreaming  are determined  by  blood supply.
Were we to  attempt to do what we dream  of  doing
then the result  would be  that we  would require
restrain during  our sleeping hours.  At these times
imagination runs riot, yet, the varied panorama which
passes before our vision transcends any effort we could
put forth in that direction in our waking  hours.  The
ideation has no check, as we see  in the frenzy of acute
mania, although  from two different  conditions  of  the
brain in its blood supply.  On the one hand we have
physiological anaemia; and on the other hand, patho-
logical congestion and cell deterioration.
  The  varied capacity of brain and  mind is thus seen
in two very different states.   We need not wonder at
the vagaries of mentality found on record  in abnormal
conditions. 
CRIME  AND RESPONSIBILITY.         291
               CHAPTER  XXX.


          CRIME AND RESPONSIBILITY.
Crime has been defined  to be a violation of human
law or the law of the State; sin, a violation of the
Divine law or the precepts of religion ; vice is oppo-
site to virtue, and is an offence against morality, or a
violation of the moral law.  Crime is  especially the
object of jurisprudence; vice, of  ethics;  and sin, of
theology.
  Responsibility is the  capacity  of  discharging an
obligation, or ability to be accountable for actions.
  We must bear these definitions in mind in discuss-
ing the relation of crime  to  responsibility.   Some
classes of humanity must be held  to be exempt from
responsibility.
  1st. The child of immature  age.
  2nd. The idiot with   arrested  brain-growth  and
dwarfed mental development.
  3rd. The imbecile in whom the mental powers exist,
but in a feeble  and circumscribed condition.
  4th. Various classes of the insane.
  5th. The epileptic (not insane), when fits are coming
on or leaving.
  6th. The dipsomaniacal in the frenzy of drunken-
ness. 
292
Mental Diseases.
  The last two classes are held in law to be  respon-
sible, whether conscious of their acts and the quality
of them  or  not.   Law  says it cannot distinguish
between  the knowing act of an epileptic  and that
done unconsciously.  It also says the drinking maniac
is in that condition because of  his  voluntary  act of
drinking; hence his  accountability.  The law holds
that all insane are irresponsible, but bases its  defini-
tion of insanity on the capacity of a person to know
the  distinction  between right and wrong  in  the
abstract.   This fulcrum mind-test was laid  down  by
the English judges in the McNaughton case (1843).
In carrying out the law, judges  never give a personal
opinion.  To them the accepted  lex  scripta is gospel
truth, as  far as  the  verdict and  execution of law
are concerned.   They do not question  the received
decisions,  authorities  and precedents of their legal
ancestry.  To  them, it is what  the law commands,
which is supposed to  be founded  on  justice in  its
fundamental principles.  We  need no other example
in this particular than that already mentioned.  To
make a knowledge of right  and wrong the crucial
test of  sanity has wrought  untold mischief in the
administration of  law.   In fact, it  is  now acknow-
ledged by eminent jurists, such as the late Sir James
Fitzjames Stephens, in his work on " Criminal Law,"
and by  Lord Chief Justice Cockburn,  in his opinion
given before a Parliamentary  Committee, that such a
rule of law is misleading and faulty.  The consequence
has been that in recent works on medical jurisprud- 
crime and responsibility.         293
ence a new element  has been  introduced  into the
legal definition.  The ethical test is not given up, but
there is added such a clause as, " the law allows that
a man who, by reason of mental  disease, is prevented
from controlling his own conduct,  is not responsible
for what he does."—(Stephens' "  Relation of Madness
to Crime ").   It is added, "No doubt there are cases  in
which madness interferes with the power of self-con-
trol, and so leaves the sufferer at the mercy of any
temptation to which he may be exposed; and, if this
can be shown to be the case, I think the sufferer ought
to be excused."—Stephens.
  In 1874, when Russell Gurney's bill was before the
English Parliament,  a clause embodying the recog-
nized fact that the moral test was very fallacious, and
that a statement should be introduced accepting  as
proof of unsoundness of mind or lack of responsibility
such brain disease as destroyed self-control.   The law
officers of the Crown recommended its rejection, and
it  was shelved accordingly.  When this   proposed
amendment was before the Committee of the House,
Lord Chief Justice Cockburn cordially accepted this
amendment, and significantly said: " The pathology
of disease abundantly establishes there are forms  of
mental disease in  which, though the patient is quite
aware he is about to do wrong, the will becomes  over-
powered by the force of irresistible  impulse.  So the
power  of self-control, when destroyed or suspended
by  mental disease, becomes, I think, an essential ele-
ment in irresponsibility." At  the  same  time, Sir 
294
mental diseases.
James Stephens suggested that in such cases a jury
should be allowed to bring in one  of  three  verdicts,
viz.: 1st, Guilty.   2nd, Guilty, but the power of self-
control was diminished by insanity.  3rd, Not guilty,
on the ground of insanity.
  The judicial instructions  to  juries in rendering
verdicts  remain  as before,  and  even Chief Justice
Cockburn was obliged to charge juries according to
the written law, although he  knew how inconsistent
with physical fact the law  is.   He was obliged to
abide by the traditions of the legal fathers.  Hang-
ing under the old definition is still going on, in spite
of the flood of  knowledge which has been poured
upon  the subject by  psychologists during  the  last
fifty-two years, since  the  moral  test formula became
law.  The more  enlightened opinions  of  eminent
jurists must ultimately have weight  in  the British
Empire and in  the United States, and will tend to
affect legislation in the right  direction.   This is not-
ably the  case in  the United States.  Newly enacted
penal codes in some of the States have, in addition to
the morality definition of 1843, some form of recogni-
tion of loss of self-control by virtue of disease.
  From these general statements it will be seen how
widely law and medicine differ on this  radical  and
all-important matter.   The medical test for insanity is
based  on the presence of physical  disease  and its
abnormal results  on conduct; the legal test  is meta-
physical  and theoretical.   The  medical diagnosis  is
based on pathology and experience ; the legal ignores 
crime  and responsibility.         295
any  physical  condition  which  does not  affect  the
moral attributes.  The  legal  cares  nothing  for  im-
pulse, loss  of  will power, or sudden change  of char-
acter and conduct without  motive or from  childish
incentives ; medicine  takes in the whole man in all
his  multifarious interests.   The former tests by  the
ambiguous notion of right and wrong; but the latter
by  the  will not or cannot of each individual.   The
one deals with an abstract idea; the other in what is
found practically true every day in the wards of any
lunatic asylum.  Law adheres to tradition and  the
fiat of statutes ;  medicine points to the facts  of clini-
cal experience  and  practical knowledge.   Legal  dicta
permit a counsel and judge to instruct a jury both as to
law and facts, both as to responsibility and value of
evidence ;  but a medical witness—whatever his experi-
ence and skill  may be—is not allowed to relate them
to the jury, although they may be of intrinsic  value in
teaching and enlightening those in whose verdict  lies
the destiny of a prisoner.  The man, of all others,
who should know whereof  he asserts, must be  " a
dumb dog," while the  man whose experience  may be
of the most crude  kind is legally allowed to appeal,
to instruct and direct  a jury in  the most abstruse of
all medico-legal subjects.   The writer, not long since,
heard at a State trial a well-known Canadian barrister.
and Queen's Counsel instruct  a  jury that any ordin-
ary man was as able to detect any form of insanity as
could an expert.  The absurdity of such  a  statement
might be  seen  any day  by turning loose into  the 
296
MENTAL DISEASES.
wards of a strange asylum this counsel, a jury, and
asylum medical officers, to select the sane from the
insane as they might  be presented.  A short experi-
ence in this discriminating work might not convince,
but  it would certainly  give ground for legal reflec-
tion and possibly prevent a repetition of such a state-
ment.  Perhaps he should not  be blamed too much,
as his text-books make the same assertion.  It would
be rank heresy for him to fly in the face of  accepted
authority, even were he convinced of its absurdity.
  In reading the history of jurisprudence, it is satis-
factory to  observe that the broad minds of the great
jurists and wise legislators are groping towards the
light.  Let us take the question under discussion, for
example, and see its evolution.
  During the last century, the definition laid  down
by  Lord  Coke was  accepted as law.   In this it was
held that to be insane meant to be totally devoid  of
mind, memory  and  understanding when an  insane
act was  committed.   If  this negative condition did
not exist, such were responsible.  It need scarcely be
said to-day that  no insanity ever existed  to  which
this  definition would apply in its entirety.
  In the beginning of this century it was held  that
insanity  should be tested  solely on the basis  of the
possession  of  delusions.  Of course, the absence  of
them would imply sanity, yet we know many insane
have no delusions.   This phase  of legal thought was
followed  by the crucial test that any  person who has
the capacity "to know the nature and quality of the 
CRIME  AND RESPONSIBILITY.         297
act he was doing"  must  be sane and responsible.
Man}- insane are quite capable of knowing as described.
This moral test is absurd in itself.  What  right and
wrong are in the abstract have not been determined.
Law is one thing and ethics may be quite another.
As one item of the curiosity of law penalty, it may be
noticed that  at the beginning of this century more
than 200 offences, from robbing hen-roosts to treason
and murder, were punishable by death in the British
Isles.   In 1816, no less than fifty-eight  persons were
under  sentence of death for such  offences, and  one
was a child under ten years of age, who  could neither
read nor  write.  As the years rolled by, it became
evident that punishment and crime  were  unequally
associated, and law began to adopt a sliding scale in
the administration of justice more in  keeping with
the quality of the crime.   Anyone who will take the
trouble to wade through the evidence on which  the
verdicts of those days were based, will see it fared
badly  with the poor lunatics.  The court  suspended
the insane, in  many instances, instead  of  the judg-
ment !  The  putting the life of  the  assumed insane
in one scale  and  then  placing these ever-changing
conditions of law in the other have been, are now,
and apparently will be  the  means of putting many
innocents to death.  Definitions are mischievous when
they bind down judges,  juries  and legal evidence to
certain lines  of  opinion,  from  which  there is no
deviation permitted.   The  results, so far, has been
that legal history in the past was full of records of the 
298
MENTAL DISEASES.
victims of crude definitions and legal subtleties.  Cast-
iron definitions have been the means of  bespattering
the pathway of nations with the blood of these more
unfortunates.
  The word insanity is a relative term, and means a
disease.  It is always a brain disease, with gradations
of severity.   As we cannot tell where the colours of
the rainbow blend, nor  can we  point out  when  the
steel-grey of the dawn commenced, nor when the  last
glow departs of the closing day, neither can we define
where sanity ceases and  insanity begins.  There  is a
borderland  which lies in the shadows,  and no  one
can penetrate it with a pencil of light.  Reason passes
into it, possibly unconsciously,  or,  it may  be, with
dread  forebodings, and  emerges from  the  ominous
cloud into the positive region of mental alienation.
The foe  comes stealthily, but surely, and ties  the
captive to his chariot-wheel.  There is at this stage
no mistake  as to the mind-trouble.   It has assumed
a definite form in its prominent features,  which is
modified by the personal characteristics of each indi-
vidual ; hence no detailed definition of insanity  can
ever be given.  No two  people  are  alike in any  one
particular, so mental manifestations differ.  In judg-
ing the insane, the temperament, peculiarities, educa-
tion, habits, surroundings and apparent motives must
always be taken into account.   Does the  man  act
naturally ?  Is  he himself ?  Is  his  unusual conduct
brought  about by anything  but  brain disease ?   We
must measure all men by their own  half-bushels,  and 
CRIME AND RESPONSIBILITY.
299
not  by  an arbitrary standard  of  capacity.  The
ascending series  of  intelligence seen in the  normal
creation have a counterpart in insanity.  If we take
an intellectual general test and apply it to each class
of the insane, we will find at the lowest points the
harmless dement in whom is little  mental capacity
beyond that found in the helpless child.  Such have
little vitality beyond organic life.   At the other end of
the  series are the cunning, clever, intelligent  insane,
who  puzzle  even  experts  in their tnost  searching
examinations,  Among  this  higher  class are  found
the  insane over  whom courts sit in judgment, and
concerning whom juries give  strange verdicts.  The
stupid, the boisterous maniac, and  suicidal and religi-
ous  melancholies are easily  known ; but the  clever
possessor of delusions which he carefully hides, and
which may be the mainspring of his general conduct,
needs to  be carefully examined, watched and studied
before the most  experienced  can  pronounce definite
judgment and determine responsibility.  These delu-
sions may be of a harmless kind, and control  or may
not  impel overt acts, or they may be mainsprings to
urge to  insane  manifestations.   Of course,  we  all
have delusions of some kind, but the judgments of
the sane  give them proper value.   The insane accept
them as facts, not fancies.  There is a large  class of
individuals between the feeble-minded and the normal
section of the community, and naturally animalism is
the predominating feature of such beings.   The intel-
lect  is developed  to such a degree that they may  be 
300
MENTAL DISEASES.
tolerable citizens as far as intelligence is  concerned.
They are,however, low in the scale,and are known to be
such by even ordinary observers.  The cunning, selfish
instincts and impulses found in animals are strongly
dominant in them.  They set lightly  on law  or  any
of its restrictions so long as they can avoid detection.
With such, it is not a  question  of  morals, but of
punishment.  The sense of right and wrong is feebly
developed, and the moral judgments are seldom exer-
cised.  Conscience is  either not  present, or, at best,
weak and functionless, and gives little trouble.  It is
not an ethical nature blunted by  repetitions of evil,
but a faculty never brought to maturity.   Such have
been called " moral idiots."  No crime, however dark
and  horrible, will  cause them to lose a  meal or a
night's rest.  Like  brutes they live, and  like  brutes
they die.  If they have not much mental  activity
they may be harmless in a community from sheer
inertia, and are  never heard of but as ne'er-do-weels;
but if  the brutal instincts goad on  the intelligence,
we have developed a low class of criminals for whom
there is little hope.  They crop up  as the  chronic
vagrant, tramp,  petty thief, or, in short, the inveter-
ably depraved all-around character. The whole being
is saturated  with  laziness and cupidity, because of
which a living is procured at the expense of the honest
workers of society.
  The fact is, all intelligent creation  is like a pyra-
mid.  The first section from the base represents the
animal instincts  of man and beast.   TJie next section 
CRIME AND RESPONSIBILITY.         301
may represent the higher intelligence, not instinctive;
it is much narrower in its scope.  The section includ-
ing the apex might typify the moral nature, and repre-
sents a much more circumscribed and higher class of
being   In humanity, the  building up of our nature
is  in the following  order from birth:  1st. Animal
instincts.   2nd. Intellectual powers.   3rd. Moral con-
ceptions.   In any or all  of  these   we  may  have
arrested development.
  Now, in the building up of this sympathetic whole
from childhood to adult life, we may find the growth
arrested at any of the stages.   If development should
be  checked in any stage  of  youth, only the animal
exists: hence the idiot and imbecile.  If arrested in the
progress of intellectual growth, we have feeble-mind-
edness and dwarfed mentality.  If  atrophy  takes
place in  the last section of building a full  manhood,
then have we intelligence, but no moral nature,  or, at
best, only the rudiments of one.
  No amount of metaphysical refinement can reason
away the physical fact that our whole entity of  body,
intellect, will, affections,   emotions  and morals  are
only manifestations  of one organic  whole, and  are
interdependent upon one  another in many relations
of this unity.  The genesis of our conduct  is largely
dominated  over  and affected by their development,
their relative  power, and  their  controlling activity.
The elements of our existence have in  them  the
potentialities of  the coming man.  Habit, education,
and  favourable surroundings do direct these primary 
302
MENTAL DISEASES.
forces for good or evil, but they never can obliterate
the characteristic features which make us congenitally
distinct from one another.  Our individuality is born
with us, and goes with us to our graves.  A very little
change  in  the  relation of our constituent element of
character and  of  primal  nature does  alter  very
much individual peculiarities,  just as  a  very little
change  in  chemical  elements  brings .about radical
differences  in  material substances.   The old  land-
marks, however, remain unchanged, and must,  in  the
nature of things, so continue.  No two physical*forms
or faces of humanity are alike; no two brains are alike ;
and no two minds are counterparts of one another,  ex-
cept in a generic sense.  The primal elements are varied,
and the growth of  brain and mind is different in each
person.  The immature brain of a child may  be fully de-
veloped into the mature and  complex brain of man-
hood, but the attempt to improve a partially dwarfed
brain, such as is seen  in  the feeble-minded, is well-
nigh hopeless.   The  juvenile brain grows, and men-
tality with  it,  in  a  corresponding ratio,  so that an
equation might be made  between the two.  A brain
has only a mental scope  equal  to its capacity  and
power.
  The child is judged  according to its mental  power,
so  ought  the  savage  and   the feeble-minded  to
be.    It  is not  by years we should measure mind
strength, but by the standard of  the ordinary intelli-
gence of the ordinary man.   There are children wise 
CRIME AND RESPONSIBILITY         303
beyond their years, and there are men with childish
minds.
  The brains of the lower forms of humanity and  of
the higher beasts come close together in structure
and shape.  The natures of both such men and beasts
have much in common.  Both have intelligence and
reasoning power, but  there is no evidence that they
have a moral sense, or, if so, it must be in a rudiment-
ary degree.  They have no contrition for acts.   Pun-
ishment, not compunction, restrains  them.  The idiot
has not  even  the animal intelligence.   The imbecile
is a step higher in the  plane of instinct and  know-
ledge,  but is  little, if  any, higher  in these than a
dog, elephant, or chimpanzee, and is held not to be
accountable because  of  mental deprivations.  The
feeble-minded  approach  more nearly to  the normal
man,  but are  lacking in keenness of judgment, the
abstractive faculty, and mental concentration.   Such
are either very childish and harmless, or show vicious-
ness or many  forms  of depraved  propensity.  The
criminal  and accountable, in the next stage, have no
keen  appreciation of  the rights of others.  Many  of
them  are children with grown bodies, just as we find
in the habits, tastes and mental scope of the untutored
savage.  The immature brain of a child, a barbarian,
and  the  weak-minded  produce  analogous mental
phenomena.  It is to  be remembered that there can
be no responsibility where there  is no  moral nature,
and there can be no moral nature where there is little
or no intellect.  The fact of a knowledge and  appre- 
304
MENTAL DISEASES.
ciation of our relation to law and of the consequences
flowing from its infraction may exist without responsi-
bility.   To simply know is one thing, but to be able
to determine and set in action responsible volitions is
quite another.
   These statements are made to help to an  apprecia-
tion of another class, which can be placed between
the feeble-minded and a fully-developed man.   We
find a large class of the community  who have,  in  a
low degree, judgment, discretion, common and moral
sense.  From  this class comes the  vicious and  low
criminal.   Reference is not here made to those who
become so by association, example and habit, but to
those who are congenitally weak  in  all the  necessary
attributes  of a  well-ordered humanity.   They start
life  handicapped  with low  cunning,  inordinate ac-
quisitiveness, selfishness, cruelty, low mental powers,
and lack of a moral  sense.  All of these deterrents
are seen in a lower plane in the brute creation.  Such
prey on the public, do no work for a livelihood, in-
dulge in petty larceny, revel in the mere performance
of wickedness for the love of it, whether sensualistic
or  destructive; in short, indulge  in  all  depraved
tastes and  vices, and never  know practically what is
meant by the stings of conscience.  A love of wrong-
doing  is an inborn  and  inbred  condition  in which
they take  delight.  As a matter of fact, the responsi-
bility  of such  is small,  measured  by  any rule of
ethics, and it is  a serious matter  to  consider if such
criminals should not  be incarcerated for life when 
CRIME AND RESPONSIBILITY.        305
they become chronics.  They should be made to earn
an honest living, not merely as a penalty for crime,
but as a charity towards the vicious, and as a protec-
tion to society  against their ravages.  Such ordin-
arily spend  most of their time in prison because of
repeated offences, and  are  let out of  durance inter-
mittently, only to prey on society, to  educate others
to follow their example, and to leave behind them  a
criminal progeny.  The low criminal, by oft convic-
tions and repeated imprisonments, becomes an incur-
able law-breaker, and should be  treated as incorri-
gible.   Experience  shows  he is such, and being so,
has forfeited  all right to  liberty and personal  con-
sideration beyond kind  treatment and forbearance,
based on industrious habits and good conduct.
  It is easily to be understood, then, that in this  next
upward stratum is found  the larger number of our
ignorant,  depraved, lazy,  bestial criminals.  Their
cunning will make them sham religion when it  suits
their  purpose, their  instability  makes  them  yield
readily to temptation, their animalism makes  them
the sport of their passions, their love of ease makes
them  indulge in the  luxury of  vagrancy  or petty
larceny,  their  low  tastes make  them  victims  of
strong drink and the  seekers of like  associates, and
their  gregarious instincts cause  them  to form   com-
binations which threaten to disturb  the  foundations
of society, and of necessity make them social pariahs.
  In view of these  facts, it is one of the great social
problems of to-day to determine, in equity, how much
    20 
306
mental diseases.
conduct is influenced by natural and irresistible qualb
ties, and  how much  is modified by  immediate  and
proximate external  causes  and  circumstances, or
wherein our actions  and modes of thought are influ*
enced and directed by our natural aptitudes and pro-
pensities.   As far as we can know these factors, they
should be taken into account in estimating the culp-
ability of actions. Law is based on abstractions, and
punishes absolutely according to act  and not accord-
ing to turpitude.  The man who commits a homicide
in a frenzy of drunkenness  has  little consideration
shown to him  in his sentence, yet culpability may
depend  largely on circumstances.   In one case, the
passion  for drink may have come on  from a vicious
and acquired habit, therefore it is blamable;  in an-
other, it may be a dipsomania by reason  of heredit-
ary transmission, from which there may be no manu-
mission.   It is a heritage of uncontrollable impulse,
which is transmitted in its invasion and continuance.
In  both classes  the  penalty is  identical,  hence  the
injustice often meted out.
  A forgery is committed  by a man whose whole life
record has been that of honesty and truthfulness, but
who, by stress  of financial  pressure, has suddenly
fallen from his high estate.  The trend  of his  whole
career has been in the direction of virtue and honest
living, but with  commercial  disaster  staring him in
the face he commits  a felony,  which  he hopes to
rectify  before  discovery.   His whole moral  nature
revolts against the act, but his sensitive fear of men 
             CRIME AND RESPONSIBILITY.         307

 and  of  the effects of  poverty on his family  and
 himself is a motive too strong to resist.
   Another man has a  mean, grasping, selfish nature.
 He  has  been naturally so from childhood.  He has
 cultivated all evil influences, and has sought environ-
 ments calculated  to  encourage  their growth  and
 deepen their  intensity.  Because of these tendencies,
 natural  and acquired, he forges and cheats simply to
 possess and increase his gains, based on the pure love
 of greed.
   The acts in both examples  are the same, but in their
 comparative guilt they are far asunder.   In the one,
 it is a sudden impulse to deviate from the well-beaten
 track of  a life-long rectitude; in the other,  it  is the
 natural outcome of an ingrained vicious nature.  The
 guilt in  both cases is scarcely  to  be  compared,  but
 the  penalty is equal.  The  motives are  not  taken
 into account.   In fact, the  man of heretofore good
 reputation is held to be the  greater culprit, although
 it was only an incident in his life, and in  the other
 the outcome of a  bad record.
  In short, it may be said that:—
  1st.  The natural history of crime shows that brains
 of chronic criminals deviate from the normal type
 and approach those of the lower creation.
  2nd. That many such are almost as impotent to
 restrain themselves from crime as the insane are in
 abnormal  conduct.
  3rd. That immoral bias may be hidden  because of
expediency  by cunning until   evoked by  circum-
stances. 
308             MENTAL DISEASES,
  4th.  No  man can  shake himself free from the
influence of the physical  surroundings  in which he
is encased.
  5th.  Crime is an ethical subject of study outside of
its penal relations.
  6th.  Insanity and responsibility may coexist.
  7th.  Some insane can make competent wills, because
rational.
  8th.  The monomaniac may be responsible should
he do  acts not in the line of his delusion, and which
are not influenced thereby.
  9th.  Many  insane are influenced  in their conduct
in the same way as the sane; the rudiments of free-
will remain,
  10th. Many insane have correct ideas in respect to
right and wrong, both in the abstract and concrete.
  11th. Many insane  have power to withstand being
influenced even by their delusions.  Therefore, irre-
sponsibility and insanity  do not always cover the
same ground. 
INSANITY AND CRIME—LEGAL POINTS.    309
CHAPTER  XXXI.
LEGAL  POINTS IN RELATION TO INSANITY AND
                     CRIME.
There are three  distinct  definitions of insanity re-
quired by British  law:
  1st. In criminal cases, the legal test of insanity is
the knowledge of  the distinction between right and
wrong;  that is, a criminal is considered sane and
responsible when he committed a crime  if "he then
knew the nature and quality of the act," and that it
was wrong.  Some jurists  hold  that  this knowledge
needs only extend to the civil law  of  the country,
and others hold that right and  wrong  must also  be
looked upon in an ethical sense.  In other words, the
indicted  person  is or is not capable to understand
and formulate moral judgments is the test of sanity
or insanity.
  2nd. In testamentary cases, the requirement of the
law  is somewhat  different.   Here  the  nature and
quality, the rightness and  wrongness of the act are
not considered.  A testator is considered sane if  he
is  "of  sound  mind, memory and  understanding;"
and, conversely, he is judged to be insane if his mind,
his memory and his understanding are unsound. 
310              MENTAL DISEASES.
  3rd.  In  the third class of  cases a third test is
required by law, and this class is the most important,
because  in  it  alone  is  the  question  of sanity or
insanity, pure and simple, of a person directly raised.
  In an inquisition in lunacy, the actual issue placed
before the jury is: " Is the subject of  this enquiry
sane or insane ?"   To this  investigation  is attached
the test: " Is the patient capable of managing himself
and his affairs ?"  This test is very widely different,
and of very far more comprehensive scope than either
of the others.
  In both the previous cases the jury have  to get, as
it were, inside the  man's mind, and to guess as  best
they may at what was the receptivity and  scope of his
consciousness and intelligence on a certain  date.  They
have to attempt to discover what he then  knew, what
his  thoughts were, and what reliability could be placed
on his memory and judgment.   It is self-evident  that
there is only one person who  can, by any possibility,
know without fail  the state and validity of a man's
memory, of  his knowledge and of  his discretion  and
judgment, and that person is the man himself.
  We  only  know by inference  and by judging from
their actions, what  the consciousness of other persons
than ourselves may be.   This is taking  for granted
that actions  in  others are accompanied by states of
consciousness and motives similar  to those which, in
us,  accompany like actions of our  own.   This  is far
from  being  an infallible guide.  We know by daily
experience that like actions  may be preceded  and 
        INSANITY AND CRIME—LEGAL POINTS.    311

accompanied by very different states of mind.  Similar
conduct may be prompted by very different motives.
It will thus be seen that our knowledge of modes  of
mind in other  people is  not intuitive, but inferential,
and therefore uncertain.
  In the  third class  of cases, however, the subject
matter of the investigation is very different.  In an
investigation or inquisition of lunacy the jury have to
determine whether the person is capable of managing
his own affairs, and this they do by immediate infer-
ence from observation of whether he does manage
himself and his affairs in a common-sense manner.
  In such  a case there is no attempt to reach the
innermost thoughts of a man, and  procuring a know-
ledge of the workings of his  mind in  its multifarious
activities.   In this  class the  law only requires us to
look at his conduct, which is open to our direct obser-
vation.  It will be seen that the distinctions made of
the first two  classes  are based upon  metaphysical
classification, while in the last class we deal with what
we perceive and judge accordingly.  The distinctions
are practically far from satisfactory, but it is well to
know that they are made by jurists.
  It used  to be the custom of judges  to regard per-
sons deaf  and dnmb  as, in the sight of  law, idiots.
This presumption  is no longer  recognized.  It has
long been  understood that persons who lack these
important senses may yet be possessed of very con-
siderable intelligence, and be  capable  of a very large
amount of culture.; The general rule  in such cases is that 
312
MENTAL DISEASES.
the court should ascertain that such a witness possesses
the requisite  amount  of intelligence, that he  under-
stands the nature of an oath, and that  being satisfied
upon these points, it should direct the witness to be
sworn and receive his evidence through  a  sworn
interpreter.  If the witness is  able  to communicate
his ideas perfectly in writing, he will be required to
adopt that as  the most satisfactory method, but if that
cannot  be done, he will be permitted to testify by
means of signs.
   Evidence given  by  a lunatic during a  so-called
" lucid interval " or during a remission of the disease
is often accepted;  but in order to render  such evi-
dence valid,  it is  in  some cases necessary that no
serious fit  of  insanity has intervened  between  the
event and  the testimony; at least no such attack as
would cloud the recollection of the witness; and, as
Allison's " Court Practice of Scotland " says :  " That
would cause him to mistake the illusions of imagina-
tion for events which actually took place."
   The testimony of idiots is not  admissible  in  courts
of law.
   The word " witness" does not merely mean cor-
poreal presence  of  an individual in court.  It also
includes the idea of the possession of sufficient intelli-
gence to observe the circumstances of the event, and
retention of memory to recollect and relate these facts,
somewhat  in  the order of  occurrence, so  as to be
understood by another party.
   It has been held in law  that some imbeciles can 
        INSANITY AND  CRIME—LEGAL POINTS.    313

give  evidence, and  the statements of  the  highest
order of intellect of this class have been accepted.
  The jury must determine  the  value  of such testi-
mony.  Although it is often difficult, in fact, impos-
sible, to gauge the mental capacity of such in regard
to right and wrong.   Some imbeciles have a wonderful
facility  to  invent lies.   Lying becomes the habitual
exercise of their minds.
  In this relation, it is to be remembered that imbe-
cility,  which  is congenital, and  the  natural  de-
mentia of old age appear very much the same.  Yet
on one point they materially differ.   In the  childish-
ness of  old age the  memory loses its  latest  impres-
sions first, and while all traces of recent events have
disappeared, there is a  distinct remembrance of many
remote  incidents.  On the  other hand, the imbecile's
memory may be trusted with regard to the events of
yesterday more than of years gone by.
  At one time, even those labouring under mild mania
were produced as witnesses, but it was seen there was
no consistency in the  sequence  of their ideas.  This
commingling of events  in the memory with delusions
of various kinds made them thoroughly unreliable, and
now-a-days such evidence is not admitted in our courts.
  The writer is of the opinion  that the evidence of
some  insane   persons  should  be received, with  the
proviso  that it would need corroborative evidence to
fully substantiate it, especially if the insane person
is delusional.   A weak or rotten  thread  in the warp
and  woof  of  the  mind  affects  to  some extent  the
robustness  of mentality.    Hence  the necessity  of 
314
MENTAL DISEASES.
caution in the  acceptance  of such  evidence.  The
question of credibility should be left to the jury after
the ex parte statements  of counsel and  the  direction
of the judge have been heard and considered. Unfor-
tunately the motives for truth or falsehood  are on  a
lower plane in the insane than in the sane. Some jurist
has said : " Every selfish act of a sane man is leavened
with some unselfishness ;  every hell-ward tendency is
redeemed by a little reaching up to heaven ; but in the
case of many  lunatics it is not so. They are almost in-
variably selfish.   Large-heartedness is a rare virtue in
the insane."  This is a sweeping statement which pro-
nounces a general truth, but makes no allowance for
many exceptions of unselfishness and kindness  seen
every day among the  insane.  It is  true, the animal
instincts remain the longest in all  cases of mental
decay, and these, apart  from  paternal impulses,  are
essentially selfish.  This stage in humanity means the
extinction  of the nobler qualities in  man, hence
motives are a crucial test  in the insane  as well as in
the sane, but with circumscribed boundaries.  These
conditions must be considered as factors in testing the
value of  insane  evidence.  The  judge,  in all cases,
determines the competency of a witness, and  the jury
his credibility.
  These important -points  are fully  discussed in
" Brown on Insanity," Roscoe's " Criminal Evidence,"
and " Best on Evidence."
  They show the difficulties which meet the  jurist in
order to arrive at the truth, when the  search for it
must  be made through such uncertain channels. 
MEDICAL  WITNESSES IN THE COURTS.     315
CHAPTER  XXXII.
      MEDICAL WITNESSES IN THE COURTS.
 A medical witness is often put in a difficult position
 when he is attempting to explain to a petit jury any
 form of  insanity which is obscure  and not maniacal.
 The jury is often told by judge and counsel that each
 member  of it is as  capable to judge of insanity as is
 an expert witness.   This statement is an echo of what
 is found  in law books  of  over a century ago,  when
 mania and insanity were held to be synonymous terms.
 The more subtle and dangerous forms of mental dis-
 order of  the quiet, cunning  and delusional type had
 been relegated in those days to innate moral depravity,
 or to the instigation  of  the devil.   In criminal cases
 the majority of  such died upon the scaffold, as they
 occasionally do now-a-days, because of the necessarily
 inexperienced juries who tried such cases, not  to state
 the prevalence of ignorance and superstition in former
 times.
   At the same time a medical witness must fearlessly
 and intelligently endeavour to explain his views to a
jury either for or against the plaintiff or the criminal.
 A few hints to him may not be out of place.
   He should endeavour to keep his mind in a semi-; 
316
MENTAL DISEASES.
judicial condition,  and be  uninfluenced except by
undoubted testimony or personal knowledge.
  He should never lose his temper in the  witness-box,
however great the provocation.  An  angry witness is
usually at the mercy of his tormentor.
  It is not well to retort on an annoying examiner by
personal sarcasm or cutting irony.  It is better to have
the sympathy of the jury under the teasing of a brow-
beating catechist  than to attempt to  copy his method
by an exhibition of " smartness."
  The witness should  keep  on solid ground by not
going beyond his  depth in hypothesis  and  theory, as
only facts are wanted.
  He may be  caught  tripping should he attempt to
split hairs over matters of which he may have only a
superficial knowledge.
  He should never attempt to  be  scholastic in his
statements, as he has to do only with the jury.   Pro-
fessional and scientific terms may be  to a jury as un-
intelligible as Choctaw.  It is seldom  that a witness
cannot explain in every-day  language  what is in his
mind, even relating to professional matters.  This an
intelligent jury  will   appreciate and weigh,  when
a learned  disquisition by   some  pedant  will be
looked  upon  as  unintelligible  jargon.   Even  the
learned witness should be like the soldier and keep his
scholastic  ammunition behind his back, to  be used very
rarely in  courts  of law,  especially  seeing that  the
Anglo-Saxon language is so prolific  in every-day
words to  explain every  variety of thought.   The 
      .. MEDICAL WITNESSES IN THE COURTS.    317

pedantic witness is usually found to be an egotist or
a silly fellow.
  A witness is sometimes asked if he is familiar with
certain  works  of  well-known authors,  or even of
obscure authors, and is also examined as to their par-
ticular views.   It is well to be sure  that the witness
is familiar with them before giving answers to such
questioning.  I remember a witness  being asked if he
was acquainted with the works of a certain author.
The name given sounded  very much like that of a
well-known writer.  The  witness  answered in the
affirmative, yet there existed no such  author.  This
fatal mistake rendered his evidence  nugatory.
  Many questions are put to a witness, and a categori-
cal  reply to each is imperatively demanded.  It is not
to be forgotten that a yes  or no may not be a correct
answer, hence caution is needed.
  The old example in our logic lessons will illustrate
this.  For instance,  the following  question  is put:
" Have you finished whipping the boy ?"  Were the
answer  given  " No," then would it mean that  you
were whipping him and still continued so to do?  Did
you answer " Yes," then  it  meant that you  had
whipped him,  but had  ceased  to  do  so.  Neither
answer would be correct had  no  chastisement taken
place.  The assumption was false, therefore would be
either of the answers.   Many a medical  witness has
been trapped into a wrong answer, on account of such
a simple logical fallacy not having been  detected.
There  is a  large  class of  interrogations  to which 
318              MENTAL DISEASES.
affirmative or negative  answers would be incorrect.
Be on the lookout for them.
   It is well not to digress from giving a direct and
sufficient reply to each question put.  Prolixity is to
be avoided, as well as the introduction of extraneous
matter largely foreign to the case.  A witness  will
have plenty of  opportunity in his  examination and
cross-examination, not to mention rebuttal testimony,
to inform the court all  he knows  of  the subject in
dispute.
   Let  no cross-examination, however severe, force a
medical witness to be, or to appear, as if he had taken
a side so strongly that all his evidence is ex parte, be-
cause of the antagonism  evoked by a  sharp counsel
endeavouring to bring his truthful statements or evi-
dence into contempt.   The  imperturbable, intelligent
and  conscientious witness will not be  driven from a
judicial position irrespective of the results to any party
in the  case.  We  are  always to remember our oath
and the sacredness of absolute truthfulness.
   Should a witness change his opinion  before giving
testimony based upon  the evidence heard, it is only
just  to the party who has subpcened him to state  the
fact  at once to the counsel.   Unfortunately, because of
our  present  faulty  system of jurisprudence under
which an ordinary jury has to determine the value of
medical testimony on matters professional, about which
they of necessity must know little, medical witnesses
can be found to give evidence for both sides.  This is
a  matter  of regret, but a witness should not allow 
        MEDICAL WITNESSES IN THE  COURTS.     319

himself to  be trapped into valuing  the merits and
demerits of other medical witnesses.  It is the province
of the jury under law to weigh the  value and relia-
bility of all evidence.
  When authors are quoted he must be  guarded in
respect to the quotation, lest part may be only given,
and thus change  the  tenor  of the meaning entirely.
Remember a part truth is the biggest  lie.  A  witness
may be asked to give his  opinion as to the respect-
ability of a medical journal from which a theory is to
be read.   We are not to forget that the magazine may
be creditable, yet individual writers  in it  may venti-
late arrant nonsense.
  The eminent barristers in  the  legal profession  are
usually very fair and  courteous to  witnesses, while
anxious to do all they reasonably can for their clients.
Occasionally one  will be found who  thinks savagery
to a witness is evidence  of forensic ability.  When a
professional witness has the misfortune to encounter
such a lawyer he  can always  appeal  to the presiding
judge for protection.   Such appeals  should, however,
be rare, and only made under the greatest provocation.
  A witness should study thoroughly all  the phases
of a case about which he is expected to testify.
  It gives  him confidence  to know  that he has all
sides  of  it  at his fingers' ends, so to speak.   This is
especially true in insanity cases.  He should never be
ashamed to declare his ignorance on any subject he is
not familiar with.
  The witness is safe to confine his evidence to what 
320
MENTAL DISEASES.
has  come under his  personal knowledge.  Hearsay
evidence is not admissible.  He may not be allowed to
quote the opinions of authors, however distinguished ;
but an examining counsel may read  quotations from
them and ask the  witness to give his opinion in re-
spect to them.
  An expert witness  is  allowed  to  hear all the evi-
dence of facts about which he has no personal know-
ledge.   He is then permitted to give his opinion on all
the evidence presented in court, taking for granted it
is true.   He is not allowed to value the  evidence in
forming his  opinion.   It must be  taken by him, as a
whole, as being undoubted truth.
  He will not be allowed to judge of the case if only
part of  the evidence is heard by him.   This is only
just, as a partial hearing might mean much misconcep-
tion of the whole case.
  An expert witness is one who is supposed, from his
opportunities  and life-work, to know  of and to be
thoroughly conversant with the subject upon which
he is called to testify.
  He is called to enlighten the  court  on the question
at issue, and is therefore more than an  ordinary wit-
ness and less than a judge.
  »Such an exalted position should impress the witness
with the importance of every word he utters.
  It is true, many judges have said hard things about
him and his vocation,  yet these should not  influence
the witness, as no judge, or counsel, or jury, can take
from him the importance  of  his truthful  evidence, 
        MEDICAL WITNESSES IN THE COURTS.     321

based upon  experience  and not upon hair-splitting,
metaphysical subtleties.  His statements may not be
heeded, and may even be the object of irony or biting
scorn, yet it is the duty of the witness to unswerv-
ingly adhere to  what his matured judgment presents
to his mind.
   A witness  with a  warped  judgment,  on whose
mind undoubted evidence has little influence, proves
thereby his incompetence  to testify  in  any medical
case.
   Technical skill  makes many witnesses valuable in
courts, and such as the  Admiralty  Court find the
evidence of experts necessary.  The maxim is accepted
that " every  person  should be believed in his own
art."
   In insanity  cases this rule  is not adopted, but in
part, because jurisprudence cares nothing for diseased
states, nor for the evidence adduced to prove them.  It
only  considers  ethical  conditions, and  the  conduct
based thereon.
   The testimony of the medical  witness  is thereby
circumscribed  to very  narrow grounds; and,  as  a
matter of fact, is so limited as to be of very little use, as
the whole extent of his knowledge and experience and
inferences therefrom is not allowed to be presented to
the jury.
   There 19 a  tendency to more latitude in  modern
times, but as precedence is against  it, that freedom is
only permissible by the grace of the court.
  A medical witness must not forget that the promise
    21 
322
MENTAL DISEASES.
of secrecy, given in the strictest professional confidence,
is not privileged from disclosure in court.   A medical
man should be  prudent, and not allow himself to be
the custodian of  secrets not  strictly necessary to his
medical practice.  Our  motto: "Fidus  in Arcanis,"
will not save us, if,  as witnesses, we  are asked to
divulge them.
  A witness may rightly come to the  conclusion that
insanity exists in a  person  from a large  number of
minor  facts in language and conduct.   They must,
however, be taken as  a whole, and a witness must not
allow himself to be cajoled into  giving an opinion on
each of these facts taken separately.   This is a com-
mon trick of counsel, whereby  ridicule is thrown upon
the evidence of such a witness.  The cumulative force
of evidence is lost in such details.
  It is also not to be  forgotten  that in language  and
conduct the sane and insane have  much in common.
So far, these cannot differentiate the  one  class from
the other.
  A witness is allowed to use notes to  refresh his
memory, but they must be the original ones, and not
copies or abstracts, even if made out by himself.

  Steps  Taken to  Admit  Patients  into  the
            Asylums in this Province.
                          0
  There are two methods legally necessary to be
adopted before a patient can  be received into an
asylum in this Province. 
        MEDICAL WITNESSES IN THE COURTS.     323

  The one requirement is designated (a) by ordinary
process, (b) the other is by virtue of a warrant.
  What is necessary in the  former step is that " two
legally qualified medical practitioners "  shall examine
a patient separately, and  if insane shall so declare in
a general  statement, which  must be followed by a
record of  observed facts upon which such an opinion
is based.   No general opinion will be taken, as specific
acts must be  stated which indicate insanity.
  To these assertions are added the  presumed facts
given by friends  and relatives.  These  alone are not
sufficient, as  they  are  only hearsay evidence.  All
blanks as to dates, the full names, and such like, must
be  filled  up.  Two  witnesses are necessary to each
signature.
  These two medical certificates are important docu-
ments, hence great  care should be exercised in filling
them up  properly.   They are  virtually a warrant to
commit a  citizen  to an  insane  asylum,  and a medical
man should appreciate his responsibility  in the matter.
  The second method is, that a warrant is issued to
arrest a person who is supposed to be  insane.  This
may be done by a constable if such a person is at
large, and has become a nuisance or a menace to him-
self or to the community.  On the other hand, an
affidavit  may be made by  a  friend, a relative,  or a
neighbour, asserting that such  a person is insane and
dangerous, or not able to look  after himself.   Based
on this sworn statement a warrant of arrest is issued
by  a magistrate,  and by virtue of it he is committed 
324
MENTAL DISEASES.
to gaol.  He is there examined  by the County judge,
the gaol surgeon and  another medical man, and if
declared insane by them he is sent under warrant to
an asylum.  A warrant of  discharge is needed, based
upon the recommendation of the superintendent.  This
dismissal warrant must be  signed by the Lieutenant-
Governor.   Under  the  ordinary  process no  such
complicated and  slow  processes  are needed.  The
simplicity of  the  one  method, and the complexity of
the others, under exactly similar conditions, show how
tenaciously we cling to obsolete and cumbersome red-
tapism.  The necessary forms should  be the  same in
all cases of insanity.   The one class should not  be
treated as criminals simply because arrested,  and the
other treated as patients, and sent as such to a  hospital
for the insane, to  be discharged by the chief officer
without any formality  when recovery takes place. 
INDEX
Amentia.....................  182
    idiocy,.................  182
    imbecility,..............  182
    distinction,  .........183, 184
    weakness of mind,........  18,1
    savage and child,........  186
    illustration,.............  187
Amyl-nitrite.................  221
Arsenic.................223
Aphasia....................   285
    different forms...........  286
    word-deafness, word-blind-
      ness, motor-aphasia,....  286
Amnesia..................  287
    different forms...........  287
Animal instincts.............  301
Admissions of patients to asyl-
  ums.......................  322
    two methods,...........,  323

Brain illustrations........1, 18, 19
    circulation of blood, cells,.   14
    nerve substance,   ....  . .   15
    relative and absolute weight,  16
    pathology,..............  27
    shape of skulls,..........  27
    changes in membranes,. ..  27
    size of brain,............  28
    atrophy and hypertrophy,.  29
    various degenerations,... 29, 30
    Maudsley, ..............  31
    infiltration and involution,.  33
    constructive  and  destruc-
      tive,  ................34, 35
    brains of  lower creations,.  303
Bromides....................  223
Brown-Sequard's formula......  226
Borderland of insanity.........  254
                              PAGE
Circular insanity.............   94
    remissions,..............   94
    intermissions,   ........   94
    time of life,  ............   99
    Dr. Willis,..............   99
   . pathology, ..............  100
Concealed insanity............  103
    object...................  103
    caution, ................  104
Conium..................217
Cannabis indica...............  218
Chloral hydrate..............  213
Crime and responsibility......  291
    different classes,  ........  291
    changes in law,..........  293
    legal  definitions,.........  296
    natural history,........307
Clinical conditions of insane  . .   35
    ansemic insanity,  ........   35
    diabetic insanity,  ......    35
    insanity of Bright's disease,   35
    metastatic insanity,......   36
Chlorides....................  179

Delusions....  ...............   47
    false concepts,..........   47
    superstitions,............   48
    classification,............   49
Dementia.................   69
    primary,................   69
    secondary,............   69
    senile,.................   69
    organic, ................   70
    toxic,    ................   70
Dialyzed opium .............  214
Dipsomania..................  265
    classes,...............  266
    treatment,..............  273 
326
INDEX.
                             PAGE
Discharge of patients from asyl-
  ums....................... 324
    two methods,............ 324

Epilepsy of the insane........ 130
    three levels of Jackson,.. 131
    grande mal,  ............ 131
    tonic and clonic spasm, .  . 132
    symptoms,.............. 132
    temporary  amnesia,...... 134
    mental automatism,...... 135
    petit mal,  ............. 135
    points of notice,.  . 140, 141, 142
    distinction  between   epi-
      lepsy and hysteria,  143, 144
    treatment,.............. 221
Ergot extract................ 215
Electricity................... 235
Expert witness.............. 320

Functional disorders.......... 249

General progressive paresis. ...  76
    symptoms,.........76, 77, 78
    mental, physical,  ......79, 80
    pathology,..........83, 84, 85
General paralysis............  76
General bodily  conditions..... 177
    classes of disease,........ 177
    trophic change,.......... 178
    dead tissues, ..   ........ 178
    kidney products,........ 179
Gold bromide................ 225

Hallucinations.............  49
    false perceptions,........  49
    sight,.............  50
    historic  persons with  hal-
      lucinations...........50, 51
    three theories of  them, ..  52
Humoral pathology........... 248
Hysterical mania............. 101
    symptoms,.............. 102
    hystero-epilepsy,......... 103
Haematoma  auris  (orthcema-
  toma)..............  ....... 156
                              PAGE

Homicidal insanity........... *'"
    classes,..............170, 171
    impulse,................ 1'"
    imperative conceptions,... 173
Heredity.................... 237
    different views,.......... 237
    formulated laws, .238, 239, 240
    transmission,............ 241
    immediate,............. 244
    double,  ............... 244
    simple,................. 244
    mediate,................ 244
    cumulative,  ...........244
Hyoscyamine................ 216
Hyoscine................... 214
Hypnotism................... 236
Insanity...................   37
    what it is not,  .........   37
    not eccentricity,......   37
    not crankism,...........   37
    not delirium,............   37
    not natural decay of old age,   37
    not idiocy nor imbecility, .   38
    what it is,...............   38
    classification,.  . . 40, 41, 42,  43
    metaphysical divisions,  ..   44
    Hippocrates and  Celsus,. .   44
Illusions....................   52
    clinical history,......__.   53
Intellectual powers........... 301
Impulse....................   55
    intellectual,  ............   55
    emotional,..............   55
    motor,..................   55
Insane ear..................  156
    causes,.................. 157
    symptoms,.............. 156
    treatment,.............. 157
Iron......................... 230
Katatonia................... 153
Legal points  in relation to in-
  sanity and  crime........... 309
    criminal  cases,........... 3og
    testamentary cases,...... 309
    inquisition in lunacy,  .. ., 3m 
INDEX.
327
                              PAGE
Moral insanity............... 122
    mode of causation,  ....... 124
    differs from wickedness, .. 126
    from moral imbecility, ... 126
    moral conceptions,......301
Mind........................  21
    mind and body,..........  21
    definitions,.............  21
    metaphysical, ...    ......  21
    physiological,...........  21
    materialism,  ............  23
    history of theories,......24, 25
    Wundt's theory,..........  26
Monobromide of camphor.....214
Melancholia................ 106
    cardinal  symptoms,  ...... 106
    bodily functions,......... 107
    simple,  delusional, stupor-
      ous,................. 109
    suicidal,............... 110
    differentiate,............ 113
    treatment,............... 228
Memoranda of notes..........  45
    life history,   ...........  45
    hereditary history, .......  46
    predisposing causes, excit-
      ing causes,............  47
Mind stress.................. 188
Masturbation................ 149
Manias.....................  56
    treatment,.......  ..... 210
Monomania..................  57
    kleptomania,............  57
    pyromania,..............  57
    erotomania,..............  57
    homicidal mania,........  57
    suicidal mania,..........  57
Mania proper................  63
    sthenic,  .................  61
    asthenic, ................  61
    frenzy,..................  63
    typhomania, ............  63
    delirium, ...............  93
    chronic,  ................  65
    acute,...................  67
                              PAGE
Notes taken at examination of
  patient.................  . 198
    organic functions,  ........ 198
    sexual functions, ........ 198
    nervous system, ......... 199
    mental symptoms,........ 199
    tables,............200, 201
Notes on life history..........  45
Nitro-glycerine.............226
Neurasthenia............... 254
    divisions................ 256
    treatment,............. 261
    tonics,................. 264
Neuratropia.................. 254
Narcomania................279
    classes.................. 279
    symptoms,.............. 280
    treatment,........... .  . 281
    prescriptions, ....282, 283, 284

Onanic insanity............. 149
    classes afflicted,......150, 151
    symptoms, .............. 153
    results, ................ 155
Opium...................... 211

Puerperal insanity............  87
    mania and melancholia, ..  87
    time of child-bearing,....  88
    at childbirth,............  88
    post-parturient period, ...  88
    sympathetic,............  89
    septic,..................  89
    phrenic,................  90
    instruments,.............  93
Paranoia.................... 159
    history,  ................ 159
    symptoms,  .............. 161
    origin, ..  ............... 163
    treatment,.............. 165
Phthisical  insanity........... 167
    latent,................. 167
    mortality, .............. 168
    trophic, ................ 169
    pathology, .............. 170 
328
INDEX.
                              PAGE
Paraldehyde................. 217
Phosphates.........:........ 230
Phosphorus................. 234
Phosphides ................. 234

Quinine.........  ........... 250

Record of autopsies.......200, 201

Simulated insanity........... 104
    reasons for it,  .......... 104
Syphilitic insanity.......... 145
    clinical features,  ........ 146
    pathology,  ..........147, 148
Sulphonal................... 217
Strychnia.................... 223
Sympathetic................. 247
Steps taken to admit patients. 322

Temperature  and pulse....... 179
    differences,  ..........180, 181
    unreliability,............ 181
Treatment of different forms.  . 202
    general observations  202, 203,
                     204, 205, 206
    puerperal mania,  ........ 207
    rest,  nursing, antiseptics,
      stimulants,............ 207
                              PAGE

Treatment— ( Continued).
    hypnotics,.............. 208
    spirits,  ..............   209
    tonics,................. 209
Treatment of mania. ........ 210
    hygiene, sanitation,...... 211
    drugs,................ 211
    prescriptions, ........... 213
    brain restraint,  rest,  .... 220
Treatment of epilepsy, mastur-
  bation and melancholia...... 221
    different remedies,   .. 222, 223,
                 224, 225, 226, 227
Treatment of  melancholia..... 228
    feeding, ............... 232
    medicines,.............. 233
    electricity,  .  ........... 235

Urea...................... 179
Uterine disturbance......... 177

Valerianate of zinc........... 226

Witnesses in courts of law. . . . 315
    points to be noted,   ....... 316

Zinc bromide...............225
/V-j 
 
 
 
;■,:!ji|i I i;i;IS
 !!:•   .: ^-Iliiini iii! ila
;;s;;::;:^-:i:Si8|||hfib
 

.' ) ir.l

      '::;:;. ■■■*-$'.
"Hi!:;; "v  .■MX1" -
I

il:!!!!'1'*..
li:..'"5''"     ■  "*'
■ 
NLM005582670